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Performance audit and sunset review, Board of Podiatry Examiners

Performance audit and sunset review, Board of Podiatry Examiners

Debra K. Davenport
Auditor General
Performance Audit and Sunset Review
Board of
Podiatry Examiners
Performance Audit Division
September • 2008
REPORT NO. 08-06
A REPORT
TO THE
ARIZONA LEGISLATURE
The is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to
improve the operations of state and local government entities. To this end, she provides financial audits and accounting services
to the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of
school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Audit Staff
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.azauditor.gov
Representative John Nelson, Chair Senator Robert Blendu, Vice Chair
Representative Tom Boone Senator Carolyn Allen
Representative Jack Brown Senator Pamela Gorman
Representative Peter Rios Senator Richard Miranda
Representative Steve Yarbrough Senator Rebecca Rios
Representative Jim Weiers (ex-officio) Senator Tim Bee (ex-officio)
Melanie M. Chesney, Director
Dale Chapman, Manager and Contact Person
Emily Chipman
Robin Hakes
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
September 23, 2008
Members of the Arizona Legislature
The Honorable Janet Napolitano, Governor
Dr. Dedrie Polakof, President
Board of Podiatry Examiners
Dee Doyle, Executive Director
Board of Podiatry Examiners
Transmitted herewith is a report of the Auditor General, A Performance Audit and Sunset
Review of the Board of Podiatry Examiners (Board). This report is in response to an
October 5, 2006, resolution of the Joint Legislative Audit Committee. The performance
audit was conducted as part of the sunset review process prescribed in Arizona Revised
Statutes §41-2951 et seq. I am also transmitting with this report a copy of the Report
Highlights for this audit to provide a quick summary for your convenience.
As outlined in its response, the Board agrees with all of the findings and plans to
implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on September 24, 2008.
Sincerely,
Debbie Davenport
Auditor General
Attachment
The Office of the Auditor General has conducted a performance audit and sunset
review of the Board of Podiatry Examiners (Board) pursuant to an October 5, 2006,
resolution of the Joint Legislative Audit Committee. This audit was conducted as part
of the sunset review process prescribed in Arizona Revised Statutes (A.R.S.) §41-
2951 et seq.
The Board's mission is to protect the health, safety, and welfare of the citizens of
Arizona by maintaining and regulating standards of practice in the field of podiatric
medicine. The Board licenses and regulates podiatrists, who specialize in the
diagnosis and treatment of the foot and its related structures. The Board's various
responsibilities include issuing and renewing licenses to qualified persons,
conducting investigations and hearings concerning unprofessional conduct or other
statutory violations, disciplining licensees who commit violations, and providing
consumer information to the public.
Board needs to improve complaint-handling practices
(see pages 9 through 17)
The Board should take several steps to address problems with its complaint-handling
practices, some of which were identified when the Office of the Auditor
General conducted its 1998 performance audit and sunset review of the Board.
Although the Board took steps to address the 1998 problems, similar problems were
found during this audit. Specifically, the Board should:
 Separate complaint investigation from adjudication—The Board typically
performs the necessary steps to investigate a complaint, but the full Board acts
as both investigator and adjudicator. This practice conflicts with the Attorney
General's guidance in the Arizona Agency Handbook, which states that to
minimize problems, decision-makers, such as board members, involved in
adjudicating a complaint should consider not participating in investigating that
complaint. Combining the investigation and adjudication of complaints can
create the appearance of bias because board members may not appear
objective when adjudicating the complaint. Therefore, the Board should identify
and implement a process that allows it to separate the investigative and
adjudicative functions. One option the Board should consider involves assigning
Office of the Auditor General
SUMMARY
page i
one of its members to conduct complaint investigation activities and then having
this board member recuse himself/herself from all other decisions and
discussions regarding the complaints he/she investigates.
 Improve complaint-handling timeliness—The Auditor General's Office has found
that Arizona health regulatory boards should typically resolve complaints within
180 days. However, it took the Board longer than 180 days to process 15 of the
106 complaints it received between July 1, 2005 and December 31, 2007.
Further, 12 of the 106 complaints remained open as of June 1, 2008, and were
open longer than 180 days, including 5 complaints for one licensee. Two factors
contribute to the Board's inability to process all of the complaints it receives in a
timely manner. First, the Board investigates complaints during its monthly
meetings. Since the Board generally meets only one day per month, complaint
investigations can take considerable time, particularly if the process requires
multiple meetings. Separating the Board's complaint investigation and
adjudication functions, as discussed above, could help it process complaints in
a more timely manner.
Second, licensees are sometimes nonresponsive to board requests for
information. According to statute, it is an act of unprofessional conduct to
withhold some types of information from the Board. A.R.S. §32-854.01(17)
states that it is an act of unprofessional conduct for a licensee to refuse "to
divulge to the board on demand the means, method, procedure, modality of
treatment, or medicine used in the treatment of a disease, injury, ailment or
infirmity." Auditors found that for 4 of the 27 complaints open longer than 180
days and for which the Board issued letters of concern or pursued disciplinary
action, the licensees did not provide information prescribed by statute and were
not sanctioned by the Board. Therefore, the Board should take action against
licensees who do not respond to requests for treatment information as
prescribed in statute. In July 2008, the Board began using subpoenas to initially
request documentation from licensees, which may facilitate how timely
licensees provide documentation to the Board.
 Improve some complaint-handling processes—Because of inadequate
processes and documentation, auditors could not always determine whether
the Board addressed all allegations indicated in a complaint, the basis for its
complaint decisions, and its consideration of a licensee's prior disciplinary
history when determining discipline for a current complaint. Further, the Board
has inconsistently communicated complaint investigation results and the
decision to the complainant. In August 2008 the Board adopted a policy for
consideration of a licensee’s disciplinary history when taking disciplinary action
against a licensee. The Board should also develop and implement complaint-handling
policies and procedures that help ensure that it completely and
appropriately addresses all complaints and documents its processing of all
complaints.
State of Arizona
page ii
Board should improve public information (see pages 19
through 25)
One of a regulatory board's important responsibilities is providing information that
allows the public to make informed decisions about using the services of licensees
whom the Board regulates. However, when auditors made calls to the Board and
asked for information, board staff did not provide complete information about
licensees. Complete information was similarly unavailable on the Board's Web site.
One problem that contributed to the lack of complete information was the Board's
database, which is incomplete and inaccurate. The Office of the Auditor General’s
1998 audit report recommended that the Board develop a complaint-tracking
database and procedures to ensure its accuracy and completeness. Although the
Board took steps to implement these recommendations, as of May 2008, only 37 of
the 123 complaints received between calendar years 2003 and 2006 had been
entered in the database. Further, auditors' tests of 113 complaint records in the
database identified at least one piece of missing information for 64 of these
complaints. Board staff are aware of these problems, have begun to address them,
and should continue to do so. The Board should also create a database report that
can detail an individual licensee's complaint and disciplinary history. As of May 2008,
such a report has not been created in the database, and instead, board staff
manually search the database for this information. This takes time and potentially
leads to information that might be missed or not accurately disclosed to the public.
A second problem affecting the information provided to the public was the lack of
written public information policies and procedures. Although the Board reported that
it had developed public information guidelines for its staff in 2006, it has not
developed formal, written policies. A board employee, who was hired as of
September 2007 and answered auditor phone calls, was unaware of these
guidelines and did not follow them. For example, contrary to board guidance, board
staff provided information on dismissed complaints and a letter of concern that dated
from more than 5 years before the auditor's call and did not provide information on
all complaints that resulted in disciplinary action. Additionally, information on the
Board's Web site is not consistent with its guidelines. To address these matters, the
Board should develop and implement written public information policies and
procedures.
Sunset factors (see pages 27 through 36)
Auditors analyzed the Board's performance in accordance with the 12 sunset factors
outlined in A.R.S. §41-2954, including its compliance with open meeting laws. In
addition to the matters already discussed above, auditors found problems in the
following areas:
Office of the Auditor General
page iii
 Meeting notice requirements—Until April 2008, board meeting notices did not
comply with A.R.S. §38-431.02(G), which requires state agencies, at least 24
hours in advance of the meeting, to include a meeting agenda with the posted
notice or inform the public where one could be obtained. Further, the Board did
not post the notice for its June 11, 2008, board meeting 24 hours in advance of
the meeting. Therefore, the Board should ensure that it complies with the open
meeting law requirement and post its meeting notices and appropriate agenda
information 24 hours in advance of the meeting.
 Meeting agendas—Although the Board significantly improved its meeting
agendas during the audit, additional improvements are needed. Improvements
already made include more clearly and specifically identifying the items to be
discussed, considered, and potentially acted upon. After these changes were
made, however, auditors still found that the June 11, 2008, board meeting
agenda listed two complaints without indicating the specific matters for
discussion or possible action. Auditors also identified circumstances where the
Board held discussions or took actions on items that had not been included on
the meeting agenda. Therefore, the Board should continue to work with the
Attorney General's Office to ensure the appropriateness of its meeting agendas
and that it restrict board business and discussion to matters that have been
appropriately included, described, and noticed on its meeting agendas.
 Examinations inappropriately conducted—One of the Board's duties involves
administering an oral examination to those seeking to become licensed as
podiatrists in Arizona. The Board inappropriately handled its December 2007
oral exam in a board meeting by failing to properly notice the meeting and
executive session, post an agenda, or take and produce meeting minutes. The
Board addressed these issues by holding a meeting to ratify its actions related
to the December 2007 oral exam. Additionally, consistent with the advice of its
Assistant Attorney General to review previous administrations of the exam to see
if this would constitute a meeting and then address any potential open meeting
law issues, the Board held a ratification meeting in July 2008.
 Executive sessions—According to A.R.S. §38-431.03, there are seven reasons
that the Board may hold executive session, including discussion or consultation
for legal advice, or receipt and discussion of information or testimony that is
specifically required to be maintained as confidential by state or federal law.
However, the Board inappropriately conducted investigative interviews, citing
witness safety concerns, in two executive sessions held during separate board
meetings in December 2007 and January 2008. During its May 2008 meeting,
the Board's Assistant Attorney General advised the Board of the problems
associated with conducting an interview in executive session, indicating that
witness fear is not a permissible reason to conduct an interview in executive
session and that the information gathered would need to remain confidential.
Therefore, the Board should ensure that it complies with A.R.S. §38-431.03 and
uses executive session only for purposes permitted by law.
State of Arizona
page iv
Office of the Auditor General
TABLE OF CONTENTS
continued
page v
Introduction & Background 1
Finding 1: Board needs to improve complaint-handling
practices 9
Complaint investigation and adjudication should be separated 9
Board has not processed some complaints in a timely manner 10
Sufficiency of complaint-handling unclear 14
Recommendations 17
Finding 2: Board should improve public information 19
Access to public information important 19
Board provides incomplete and/or inaccurate complaint information 20
Board’s database incomplete and inaccurate 21
Board staff lacks clear public information guidance 23
Recommendations 25
Sunset Factors 27
Agency Response
TABLE OF CONTENTS
concluded
page vi
State of Arizona
Tables:
1 Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2006 through 2008
(Unaudited) 6
2 Status of Complaints Received
Between July 1, 2005 and December 31, 2007
As of June 1, 2008 11
3 Evaluation of Board Documentation
for Complaint Resolution 15
Figures:
1 Directory Search Results, Web Site Screen #1 21
2 State of Arizona Podiatrist Information, Web Site Screen #2 22
The Office of the Auditor General has conducted a performance audit and sunset
review of the Board of Podiatry Examiners (Board) pursuant to an October 5, 2006,
resolution of the Joint Legislative Audit Committee. This audit was conducted as part
of the sunset review process prescribed in Arizona Revised Statutes (A.R.S.) §41-
2951 et seq.
Field of podiatry
The American Medical Association defines "podiatry" as "the branch of medicine that
deals with the examination, diagnosis, and treatment of diseases and malfunctions
of the foot and its related structures." Under A.R.S. §32-801, podiatrists are allowed
to work on any part of the leg below the knee. However, they are not allowed to
administer general anesthesia or perform amputations. Typical foot problems treated
by podiatrists include foot and ankle injuries, bunions, heel spurs, arch problems,
and a variety of diabetes-related problems. Podiatrists generally obtain bachelor's
degrees before entering a 4-year Doctor of Podiatric Medicine program.
Board history and responsibilities
The Board was originally created as the State Board of Chiropody Examiners and
renamed the Board of Podiatry Examiners in 1964. The Board's mission is "To protect
the health, safety, and welfare of the citizens of Arizona by regulating and maintaining
standards of practice in the field of podiatric medicine." The Board has various
responsibilities that are designed to help accomplish its mission, including:
 Issuing and renewing licenses to qualified persons;
 Conducting investigations and hearings concerning unprofessional conduct or
other statutory violations;
 Disciplining violators; and
 Providing consumer information to the public.
In Arizona, podiatrists
may treat any part of the
leg below the knee.
Office of the Auditor General
INTRODUCTION
& BACKGROUND
page 1
Licensure requirements
As part of its responsibilities, the Board issues licenses to qualified applicants.
Qualifications needed to obtain licensure include passing the National Board of
Podiatric Medical Examiners' national board exams with a 75 percent or better score,
graduating from podiatry school, completing a 1-year internship/residency, and
paying the associated $225 licensing fee. Applicants must also take the State's oral
exam and pass with at least a 75 percent score. The Board administers this exam
twice a year, which focuses on Arizona statutes that pertain to the practice of podiatry
in the State. Applicants must pay a $450 fee to take the state oral exam. Statutes also
allow for the Board to issue a provisional license if an applicant meets all of the other
requirements, but has not completed a 1-year internship. However, according to its
staff, the Board has not issued a provisional license in several years.
Podiatrists who are licensed in another state can apply for licensure by comity. To
obtain licensure by comity, the applicant must have practiced podiatry in another
state for not less than 5 years within the 7 years immediately preceding his/her
application for a license in Arizona. In addition, the applicant must also meet all other
requirements for regular licensure, such as graduating from podiatry school and
passing the state oral exam.
Licensees are required to renew their licenses annually. To obtain this renewal,
licensees must complete 25 hours of continuing education in podiatric medicine and
pay a $275 renewal fee. According to board staff, in fiscal year 2007, the Board
issued 14 initial licenses and renewed 346 licenses.1
In addition to issuing licenses, the Board registers licensees to dispense prescription
drugs and devices in Arizona. Licensees must complete an application, submit a
current Drug Enforcement Administration Certification of Registration, and pay the
associated $200 registration fee to become registered. Additionally, this registration
must be renewed annually. In addition to the authority to dispense prescription drugs,
registration authorizes licensees to dispense devices for podiatric care, which,
according to the Board, include ankle or foot orthotics and various braces. In fiscal
year 2007, the Board issued or renewed 228 drug and device dispensing
registrations.2
Regulation of licensees
The Board investigates and adjudicates complaints involving potential statutory
violations and unprofessional conduct by licensed podiatrists, as authorized by
statute. A.R.S. §32-852 states that the Board may, after notice and a hearing,
suspend, revoke, or refuse to issue a license upon proof against the applicant or
The Board issued 14
initial and 346 renewed
licenses in fiscal year
2007.
1 Board staff reported that this information came from the Board's database, which contains unaudited information.
2 Board staff reported that this information came from the Board's database, which contains unaudited information.
State of Arizona
page 2
licensee for six actions that constitute statutory violations for licensees. These actions
are:
 Willfully revealing privileged communication except as required by law;
 Making false or fraudulent statements on a licensing application or
examinations;
 Having a professional association with or lending the use of his/her name to an
unlicensed podiatrist or an illegal practitioner of any of the healing arts;
 Violating A.R.S. §32-854, which states that a license to practice podiatry shall not
be issued to a corporation, partnership, or association, but two or more licensed
podiatrists may occupy and practice in the same office space;
 Being guilty of other conduct that disqualifies the licensee to practice podiatry
with regard to public safety and welfare; and
 Being guilty of unprofessional conduct as defined in A.R.S. §32-854.01.
A.R.S. §32-854.01 further defines unprofessional conduct as 24 different actions,
including advertising in a false, deceptive, or misleading manner; habitual
intemperance in the use of drugs and alcohol; inappropriate use of prescription
drugs; gross malpractice, repeated malpractice, or any malpractice resulting in the
death of a patient; and any conduct or practice which is or might be harmful or
dangerous to the health of the patient.
Allegations of unprofessional conduct may be generated by the public, other
podiatrists, the Arizona Podiatric Medical Association, healthcare institutions, and the
Board. According to board practice, upon receiving a complaint alleging that a
licensee violated statute, board staff notify the named licensee of the complaint and
request that the licensee respond to the allegations and submit pertinent medical
records. The Board then performs additional investigative steps depending on the
circumstances of the case and the type of information that is needed. Investigative
steps may include reviewing submitted medical documentation; interviewing the
licensee, complainant, or witnesses; requesting medical documentation from other
doctors who may have treated a complainant; and seeking evidence through
ordering licensees to submit to drug or psychiatric evaluations. A complaint is
adjudicated when the Board has determined that adequate information has been
obtained to determine whether a violation has or has not been committed.
If after completing its investigation the Board finds that the information is or may be
true, the Board may request an informal interview with the licensee. If the licensee
refuses to attend the informal interview or the results of the interview indicate that
license suspension or revocation may be in order, the Board is required by statute to
issue a complaint and conduct a formal hearing. The Board may conduct the formal
hearing itself or refer the complaint for formal hearing to the Arizona Office of
Office of the Auditor General
page 3
Administrative Hearings to be heard by an administrative law judge. Upon its own
determination or the recommendation of the administrative law judge, the Board
resolves the complaint. If the Board determines the allegations are true, but not of
sufficient seriousness to merit suspension or revocation, the Board can take the
following actions:
 File a letter of concern, which is an advisory letter to notify a podiatrist that
although there is insufficient evidence to support a disciplinary action, the Board
believes the podiatrist should modify or eliminate certain practices and that
continuation of the activities that led to the information being submitted to the
Board may result in action against the podiatrist's license;
 Fix a period and terms of probation;
 Issue a decree of censure;
 Issue a civil penalty of not more than $2,000 per each violation; and/or
 Issue a nondisciplinary order for continuing medical education.
However, if after a formal hearing the Board finds the licensee to be guilty of violating
A.R.S. §32-852, the Board may take the following actions:
 Issue a decree of censure;
 Fix a period and terms of probation; or
 Suspend or revoke a license.
In fiscal year 2007, the Board opened 38 complaints. As of May 2008, board staff
reported that of these 38 complaints, 3 remain open, 30 were dismissed, 4 resulted
in the Board’s issuing a letter of concern, and 1 resulted in the Board’s taking
disciplinary action by issuing a decree of censure.1
Organization and staffing
The Board is made up of three licensed podiatrists and two public members, each
appointed by the Governor to 5-year terms. The Board employs one employee—a
full-time Executive Director who is responsible for most of the Board's administrative
functions, including processing licensing applications, assisting the Board with
complaint handling, and responding to public information requests. In addition, the
Board contracts with the Department of Administration for the use of certain support
services and staff, such as accounting services, financial reporting, and
recordkeeping.
1 Board staff reported that this information came from the Board's database, which contains unaudited information.
State of Arizona
page 4
Budget
The Board derives its revenues from examination and license fees, and registration
fees for licensees to dispense drugs and medical devices. The Board deposits 90
percent of its revenues into the Podiatry Fund and the remaining 10 percent of
revenues into the State General Fund. Table 1 (see page 6) illustrates the Board's
actual revenues and expenditures for fiscal years 2006 through 2008. Due to
increased revenues and decreased expenditures, the Board's financial situation
improved in fiscal year 2008. Specifically, the Board's revenues increased by
approximately 3.4 percent from fiscal years 2006 to 2007, but increased by more
than $31,000, or 25.7 percent, from fiscal years 2007 to 2008. Revenue amounts vary
each fiscal year depending upon when the Board receives and processes the license
and registration fees it collects from April through August of each year. Additionally,
during this time, expenditures had slightly decreased. Specifically, the Board's
expenditures decreased by nearly $11,600, or 9.7 percent, from fiscal years 2007 to
2008. Most of this can be attributed to the savings that resulted from the Board's
executive director position, which was vacant during part of fiscal year 2008, and to
hiring a new executive director who was paid a lower salary than the previous
executive director. However, an $11,400 increase in professional and outside
services costs for temporary clerical help in fiscal year 2008 partially offset these
savings. As a result, the Board's fund balance increased by more than $19,000 to
nearly $86,800 from fiscal year 2006 to 2008.
Despite this improved financial performance in fiscal year 2008 and in response to a
decreasing fund balance in fiscal year 2007, in April 2008, the Board voted to
increase its oral exam fee from $450 to $750, its initial licensure fee from $225 to
$300, and its license renewal fee from $275 to $300. These proposed fee changes
will require revisions to the Board's administrative rules. According to board staff,
these rule revisions are in process and should be completed by June 2009.
Followup to 1998 performance audit and sunset review
The Office of the Auditor General previously performed a performance audit and
sunset review of the Board in 1998 (see Report No. 98-15). The 1998 audit found that
the Board should improve complaint handling by separating its investigation and
adjudication processes, reviewing licensees' disciplinary history to help determine
appropriate discipline for new complaints, and improving its documentation of the
Board's rationale for its decisions. Although the Board took steps to implement these
recommendations, during the current audit, auditors determined that the Board still
needs to take steps to improve its complaint handling. For example, the Board still
needs to separate its investigation and adjudication processes, as well as better
document various aspects of its complaint-handling process, including documenting
the rationale for its decisions (see Finding 1, pages 9 to 17).
Office of the Auditor General
page 5
Additionally, the 1998 audit found that the Board should provide more complete
information to the public by developing and validating a complaint-tracking database
and adopting procedures to ensure the continuing accuracy and completeness of
information in this database. Although the Board took steps to implement these
recommendations, during the current audit, auditors found that the Board still needs
to provide more complete information to the public and that the information in the
Board's complaint database is incomplete (see Finding 2, pages 19 to 25, for more
information).
State of Arizona
page 6
2006 2007 2008
Revenues:
License and registration fees $108,575 $106,425 $134,7921
Examination fees 7,250 12,689 12,600
Fines, forfeits, and penalties 1,800 2,650 2,700
Other 433 270 3,275
Total revenues 118,058 122,034 153,367
Expenditures, operating transfers, and remittances to the State General Fund:2
Personal services and employee-related 72,522 84,813 60,6023
Professional and outside services 26,789 24,988 36,4284
Travel 432 785 534
Other operating 5,387 8,355 9,860
Equipment 267 207
Total expenditures 105,130 119,208 107,631
Operating transfers out 800
Remittances to the State General Fund5 11,806 13,103 15,337
Total expenditures, operating transfers, and
remittances to the State General Fund
116,936 132,311 123,768
Excess (deficiency) of revenues over expenditures,
operating transfers, and remittances 1,122 (10,277) 29,599
Fund balance, beginning of year 66,333 67,455 57,178
Fund balance, end of year $67,455 $57,178 $86,777
Table 1: Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2006 through 2008
(Unaudited)
1 License and registration fees are primarily collected during April through August of each year. Amounts fluctuated
between 2006 and 2008 because in 2008 more receipts were received and processed later in the period.
2 Administrative adjustments are included in the fiscal year paid.
3 Amount decreased significantly in 2008 primarily because the Board did not have an executive director for
approximately 10 weeks and the new executive director was paid a lower salary than the previous executive director.
4 Amount increased significantly in 2008 primarily because temporary services were used when the Board did not
have an executive director.
5 As required by A.R.S. §32-806, the Board remits 10 percent of all revenues to the State General Fund. In addition,
in 2007, the Board remitted a $1,000 civil penalty to the State General Fund.
Source: Auditor General staff analysis of the Arizona Financial Information System (AFIS) Accounting Event Transaction
File for fiscal years 2006 through 2008; and for fund balances, the AFIS Management Information System Status
of General Ledger—Trial Balance screen for fiscal years 2006 through 2008 as of August 6, 2008.
Scope and methodology
This performance audit and sunset review focused on the Board's complaint
investigation and adjudication processes, and its policies and practices for providing
information to the public. The Board's performance was also analyzed in accordance
with the 12 statutory sunset factors. This report includes findings and
recommendations in the following areas:
 Although the Board typically performs the necessary complaint investigative
activities, it should separate the investigation and adjudication of complaints,
process complaints in a more timely manner, and improve various aspects of its
complaint process; and
 The Board should improve the information it provides to the public by ensuring
the completeness and accuracy of information in its database, as well as
developing and implementing consistent policies and practices for providing
information to the public.
In addition, this report contains a response to the 12 statutory sunset factors.
Auditors used various methods to study the issues addressed in this report. These
methods included interviewing board members, the Board's Executive Director, the
Board's Assistant Attorneys General, and a representative of the podiatric
professional association; attending seven of the Board's regular monthly meetings
from December 2007 through June 2008 and two ratification meetings in February
and May 2008; reviewing the Board's statutes, rules, and practices; and reviewing the
Arizona Agency Handbook published by the Attorney General's Office. In addition, the
following specific methods were used:
 To assess the timeliness and adequacy of the Board's processes for
investigating and adjudicating complaints, auditors reviewed and conducted
analyses of the following:
o A judgmental sample of 18 complaints the Board received during fiscal year
2006 through the first half of fiscal year 2008, including a sample of 5
dismissed complaints and all 13 complaints where the Board took
disciplinary action; and
o All 106 complaints the Board received during fiscal year 2006 through the
first half of fiscal year 2008 for timeliness of processing, including files for all
13 complaints processed over 180 days and where the licensee appeared
to have delayed sending documentation to the Board.
In addition, auditors reviewed the Board's complaint-handling documentation
and monthly board meeting minutes from July 2005 through June 2008.
Office of the Auditor General
page 7
 To determine whether the Board provides the public with accurate and complete
information regarding licensee complaint histories and disciplinary actions,
three auditors posing as members of the public made telephone calls to the
Board requesting information on three licensed podiatrists and compared the
information received to the Board's licensee files and database. Further, auditors
reviewed the Board's database for completeness by comparing complaints
entered in the database to all 168 complaint files the Board received from
January 1, 2003 through December 31, 2007. Additionally, auditors tested 113
complaints in the database for the completeness of five fields that contain
complaint information, such as complaint number, description, status, and
disposition. Auditors also observed board staff's processes for using the
database to access the disciplinary history of a licensee. Further, auditors
reviewed the Board's Web site to determine what information is available to the
public and to determine the accuracy of complaint information reported in
disciplinary histories for five licensees. Finally, auditors reviewed the Board’s
public information guidelines and records retention policy.
 To develop information for the Introduction and Background, auditors reviewed
the Auditor General's 1998 performance audit and sunset review of the Board
(see Report No. 98-15); gathered and analyzed information about the Board
from the Arizona Financial Information System (AFIS) Accounting Event
Transaction File for fiscal years 2006 through 2008, and AFIS Management
Information System Status of General Ledger—Trial Balance screen for fiscal
years 2006 through 2008 as of August 6, 2008; and reviewed information from
the American Medical Association’s Web site, the Board's database, and other
board documents.
 To gather information for the sunset factors, auditors reviewed and analyzed a
judgmental sample of 4 of the 20 license applications the Board approved in
fiscal year 2007; an analysis of the Board's administrative rules performed by the
Governor's Regulatory Review Council staff; and the Board's compliance with
open meeting laws, including its statement of disclosure filed with the Arizona
Secretary of State's Office as of January 11, 2008, and board meeting notices,
agendas, and minutes. Auditors also reviewed information from the Master List
of State Government Programs, the American Podiatric Medical Association,
and various board contracts.
This audit was conducted in accordance with government auditing standards.
The Auditor General and staff express appreciation to the board members and the
Executive Director for their cooperation and assistance throughout the audit.
State of Arizona
page 8
Board needs to improve complaint-handling
practices
The Board of Podiatry Examiners (Board) should take several steps to improve its
complaint-handling practices, some of which were identified in the Auditor General's
1998 performance audit and sunset review of the Board (see Report No. 98-15). First,
the Board should separate the investigation of complaints from the adjudication of
complaints. Second, the Board should ensure that it processes all the complaints it
receives in a timely manner. Finally, the Board needs to establish and implement
policies and procedures for various aspects of the complaint-handling process,
including ensuring that it has investigated and adjudicated all complaint allegations,
clearly communicating and documenting the basis for its decisions, and considering
a licensee's disciplinary history when determining discipline.
Complaint investigation and adjudication should be
separated
As was previously recommended in the Office of the Auditor General’s 1998 report,
the Board should separate the investigation of complaints from the adjudication of
complaints. Although the Board took steps to address this recommendation after the
1998 report, auditors' review of board complaint investigation practices and
observations of monthly board meetings between December 2007 and May 2008
found that the Board typically performs the necessary complaint investigative steps
but does not separate the investigation of a complaint from its adjudication. When a
complaint against a licensee is received, the Board's staff requests that the licensee
prepare a response and provide all relevant documentation. During its meetings, the
full Board reviews and discusses complaint-related documentation, determines if
additional documentation is needed and then requests it, interviews complainants if
necessary, and conducts investigative interviews of licensees and other witnesses if
Office of the Auditor General
page 9
FINDING 1
necessary. Following the investigation by the full Board, the Board adjudicates the
complaint and may take various actions such as dismissing the complaint,
scheduling and conducting an informal interview, or referring the matter to formal
hearing, typically with the Office of Administrative Hearings.
The Board's practice conflicts with guidance provided by the Arizona Attorney
General's Office. The Attorney General's Arizona Agency Handbook states that to
minimize problems, decision-makers, such as board members, involved in
adjudicating a complaint should consider not participating in investigating that
complaint. The Board told Auditor General staff that it investigates complaints as a
full board because of the medical expertise required to conduct investigations, which
the three professional board members possess, and because the Board does not
have the resources needed to hire an assistant who is knowledgeable in the field of
podiatric medicine and expert enough to begin investigations on his/her own.
However, combining the investigation and adjudication of complaints can create the
appearance of bias because board members may not appear objective when
adjudicating the complaint.
To help reduce the appearance of bias, the Board should separate its investigative
and adjudicative practices. According to the Arizona Agency Handbook,
investigations can normally be conducted by the Board's staff. However, the Board
has reported that its Executive Director does not have the time or medical knowledge
to complete investigations. Given its limited resources, the Board should identify and
implement some other process that allows separation of the investigative and
adjudicative functions. For example, the Board could assign one of its members to
conduct complaint investigations. This board member could then perform all
necessary complaint investigative activities, such as reviewing all relevant medical
documentation; conducting necessary interviews of the complainant, licensee, and
other appropriate witnesses; and developing an investigative report for submission
to the Board. This board member should then recuse himself/herself from all other
decisions and discussions regarding the complaints he/she investigates.
Alternatively, the Board could determine whether current or retired podiatrists would
volunteer services to the Board to assist in conducting complaint investigations or
identify a combination of methods that would allow it to separate the investigative and
adjudicative functions.
Board has not processed some complaints in a timely
manner
The Board needs to take steps to improve the timeliness of complaint handling.
Although the Board generally processes complaints in a timely manner, it has taken
excessive amounts of time to resolve some complaints. These delays typically
resulted from the Board's practice of investigating complaints during board
meetings, as well as licensees' nonresponsiveness to the Board's requests.
The Board could
assign one member to
investigate complaints;
this member should
not participate in its
adjudication.
State of Arizona
page 10
The full Board both
conducts complaint
investigations and
adjudicates their
outcome.
Some complaints not processed in timely manner—The Auditor
General's Office has found that Arizona health regulatory boards should typically
resolve complaints within 180 days. Additionally, according to the Governor's
executive budget report, the Board has set a goal to complete investigations within
70 days. As illustrated in Table 2, although the Board resolved 79 of the 106
complaints it received between July 1, 2005 and December 31, 2007, within 180
days, it took the Board longer than this time period to resolve 15 complaints.
Further, 12 of the 106 complaints remained open as of June 1, 2008, and were
open longer than 180 days, including 5 complaints for 1 licensee.1 Specifically:
 Licensee with seven open complaints—One licensed podiatrist has seven
open complaints with the Board, including five complaints that have been
open between 200 and over 920 days as of June 1, 2008. According to board
meeting minutes, the initial complaint filed against this licensee in November
2005 alleged unprofessional conduct and excessive billing. Although this
complaint has remained open for
nearly 2½ years, six more complaints
were filed against this licensee in
January 2006, May 2006, September
2006, and November 2007, and two
in May 2008. Allegations against the
doctor include excessive billing,
unsanitary office conditions,
fraudulent billing, practice below the
standard of care and treatment, and
unprofessional conduct with a cease
and desist from any further
communication with the patient or
the patient's family.
The Board said it has been unable to resolve these complaints because it has
not obtained all the information it needs to adequately investigate them. For
example, according to board meeting minutes, the Board attempted to
schedule an initial investigative interview with the licensee at several board
meetings between April and November 2006 in an effort to gather evidence.
However, these interviews have been continually postponed for various
reasons, including at the request of the licensee's lawyers, to allow the
licensee to seek new counsel, and because the Board scheduled other
investigative activities. The Board again scheduled an investigative interview
for its January 2008 board meeting, but was not able to conduct it until the
May 2008 meeting because of the licensee’s requests to postpone the
interview.
Twenty-seven of 106
complaints were open
longer than 180 days.
1 The 12 complaints open past 180 days as of June 1, 2008, include 3 complaints associated with lawsuits that the Board
was monitoring. The remaining 9 complaints were open between 181 and 935 days.
Office of the Auditor General
page 11
Complaint Outcome
Number of
Complaints
Complaints Open
Past 180 Days
Open 12 12
Dismissed 80 8
Letter of concern or
discipline 14 7
Total 106 27
Table 2: Status of Complaints Received
Between July 1, 2005 and December 31, 2007
As of June 1, 2008
Source: Auditor General staff analysis as of June 1, 2008, of all complaints received
by the Board between July 1, 2005 and December 31, 2007.
Investigating complaints
during board meetings
contributes to delays in
processing.
According to board meeting minutes, additional delays resulted from attempts
to schedule a psychiatric evaluation. In November 2006, and in response to
four complaints that alleged excessive office visits, excessive billing, and/or
unsanitary office conditions, the Board ordered the licensee to obtain an
independent psychiatric evaluation. However, the doctor did not receive the
information necessary to comply with the order until January 2007 and as of
June 2008, the licensee had still not complied with this board order, disputing
the Board's choice of psychiatrist, not scheduling the appointment, and
refusing to agree with the psychiatrist's terms of service.
Finally, the licensee has not complied with multiple board orders issued to
obtain evidence, including several subpoenas. For example, in January 2006,
the Board subpoenaed documentation related to the first complaint. In March
2006, the Board added an allegation to the complaint for failure to comply with
the subpoena. At its August 2006 meeting, the Board still had not received a
response to the subpoena and requested a "definitive response" for the
requested records. Despite the licensee's nonresponsiveness, it was not until
its May 2008 meeting that the Board opened a seventh complaint to address
the licensee's noncompliance.
Since some complaint investigations take so long, licensees with potential
problems can continue to practice unchecked. Although complaints must be
properly investigated for the Board to determine whether the alleged statutory
violations are substantiated, lengthy investigations do not adequately serve the
public because licensees who are the subject of valid complaints can continue to
practice for long periods without receiving appropriate disciplinary action and
without addressing the problems identified.
Two factors contribute to delays—Two factors contribute to the Board's
inability to process all the complaints it receives in a timely manner. Specifically:
 Board investigates complaints during board meetings—As discussed above,
the full Board conducts complaint investigations and does so in its board
meetings. The Board generally meets only 1 day per month and as a result,
generally only investigates complaints 1 day per month. Auditors observed
during several board meetings that the Board tabled complaint investigations
pending the request and review of additional medical documentation. This
delays investigations until the Board's next scheduled board meeting, typically
the following month.
Additionally, the Board scheduled investigative interviews for 22 of the
complaints that were open longer than 180 days, but did not schedule 15 of
these interviews for another 2 to 5 months after determining an interview was
needed. As of June 1, 2008, for the 13 interviews which the Board had
Long complaint
investigations can result
in licensees continuing
to practice unchecked.
State of Arizona
page 12
conducted, the average length of time that passed between the date that the
Board determined to hold the interview and when the Board actually
conducted the interview was approximately 103 days. The Board reported that
delays in holding interviews are sometimes necessary because the licensee
may have professional obligations already scheduled for the day of the board
meeting. Separating the Board's complaint investigation and adjudication
functions should help the Board process complaints in a more timely manner,
since investigative activities would be conducted outside of the Board's
meetings.
 Board does not take action when licensees are not responsive—
Investigations are delayed when licensees under investigation do not
cooperate with board requests. Specifically, the Board's initial step in the
investigation process is to request all medical records associated with a
complaint, as well as the licensee's explanation of the case. When licensees
delay responding to the request, this delays the Board's investigation
activities. For 12 of the 27 complaints that took more than 180 days to resolve,
the licensee delayed sending the Board the requested documentation. For
example, in January 2006, the Board received a complaint involving patient
treatment that resulted in the amputation of a toe. At this time, board staff
requested that the licensee provide relevant patient documentation. The
licensee did not fully respond to this request for documentation, but the Board
did not decide to subpoena the documentation until its March 2006 meeting—
almost a month and a half later. The licensee's lawyer provided the requested
documentation to the Board in April 2006 but also told the Board that his client
had not received the subpoena. In addition, the licensee did not provide a
written explanation of the case until early May 2006. Due to these and other
delays, such as a 3-month delay in drafting the consent agreement and order,
the Board took 15 months to investigate and resolve this complaint.
A licensee withholding some types of information requested by the Board
constitutes an act of unprofessional conduct. According to A.R.S. §32-
854.01(17), it is an act of unprofessional conduct for a licensee to refuse "to
divulge to the board on demand the means, method, procedure, modality of
treatment, or medicine used in the treatment of a disease, injury, ailment or
infirmity." However, the Board has not regularly taken action against licensees
who have not responded to subpoenas or written requests for medical
documentation associated with complaints. For example, for 4 of the 27
complaints that were open longer than 180 days and for which the Board
issued letters of concern or pursued disciplinary action, the licensed podiatrist
did not respond in a timely manner to the Board's request for documentation.
However, the Board did not sanction the licensees for the failure to respond in
a timely manner, even though the licensees were required to provide to the
Board the type of information prescribed by statute. The Board said it had not
pursued action against licensees because it previously believed that it could
Office of the Auditor General
page 13
The Board has not
regularly taken action
against licensees who
have not responded to
requests for information.
only take action against a licensee after both requesting the documentation
and then subpoenaing the documentation. Therefore, the Board should take
action against licensees who do not respond in a timely manner to requests
for treatment information as prescribed in statute.
In July 2008, after audit work was completed, the Board began using
subpoenas to initially request documentation from licensees. Further, in
August 2008, the Board formally adopted a policy to use this approach. A.R.S.
§32-852.01(H) gives the Board authority to subpoena witnesses, documents,
and other evidence as needed. Using a subpoena may facilitate receiving
documentation in a timely manner because according to statute, the superior
court may hold a person who refuses to obey a subpoena in contempt of
court.
Sufficiency of complaint-handling unclear
Whether the Board is fully carrying out some parts of its complaint-handling process
is unclear. Specifically, auditors could not always determine whether the Board
considered all allegations indicated in a complaint, the basis for its complaint
decisions, and its consideration of a licensee's disciplinary history when determining
discipline. Further, the Board has inconsistently communicated complaint
investigation results and its decision to the complainant. Inadequate processes and
documentation increase the risk that board actions may appear to be inconsistent or
biased when violations or concerns appear similar but involve different decisions.
Adequacy of some complaint processing uncertain—Because of
inadequate processes and documentation, auditors could not determine whether
the Board adequately processed all complaints reviewed. Specifically:
 Consideration of all complaint allegations unclear—Auditors were unable to
determine whether the Board addressed all of the allegations identified in
complaints. Although the Board lists complaint allegations in various
documents, including a letter when it requests licensees to appear before the
Board for an investigative interview or in board meeting minutes, these
documents do not clearly indicate that the Board addressed all of the
complaint allegations. Specifically, auditors’ review of a judgmental sample of
18 complaints received by the Board between July 1, 2005 and December 31,
2007, found documentation supporting that the Board addressed all of the
complaint allegations for only 8 of the 18 complaints. For example, the Board
issued a letter of concern due to inadequate record-keeping for 6 of the
complaints reviewed. However, complaint documentation and board meeting
minutes do not clearly explain whether the Board addressed the additional
indicated allegations of practice below the standard of care for these
complaints.
The Board does not
clearly address all
complaint allegations.
State of Arizona
page 14
 Basis for decision not always clear—Neither board meeting minutes nor
complaint files consistently document enough information to explain the
Board's decisions to dismiss complaints or issue letters of concern. As shown
in Table 3, auditors' review of a sample of 18 complaints received by the Board
between July 1, 2005 and December 31, 2007, found documentation
explaining the results of the Board's
investigation and/or basis for its decision for
11 of these complaints. These include the 4
complaints where the Board took some
form of disciplinary action, such as placing a
licensee on probation. However, for 2
complaints that the Board dismissed with a
nondisciplinary letter of concern, although
board meeting minutes explain the Board's
rationale for issuing the letter of concern,
complaint documentation does not explain
the Board's decision to dismiss the
complaint. Finally, for the remaining 5
complaints, including 2 dismissed and 3
dismissed with a letter of concern, neither
complaint file documentation nor board
meeting minutes adequately explain the
basis of the Board's complaint decision.
Additionally, although the Board generally discusses the basis for its
complaint decision during the board meeting, auditors observed that for 3 of
the 14 cases processed between December 2007 and May 2008, the Board
did not clearly explain its reasoning.
 Consideration of disciplinary history not clear—Although the Board reported
that it considers a licensee's disciplinary history, including any letters of
concern, when determining discipline for a new complaint, consideration of
this information and its use in helping to determine appropriate discipline is
not documented. Specifically, the Board imposed discipline against licensees
for 4 of the 18 complaints reviewed by auditors. Two of these four licensees
had previously received discipline. However, complaint file documentation
and/or meeting minutes do not indicate whether the Board received or
considered information on these licensees' disciplinary histories when
determining the discipline for the new complaints. The Board indicated that it
sometimes relies on the historical knowledge of board members for this
information or requests the information from staff. Yet, at the December 2007
board meeting, auditors observed the Board considering and then taking
disciplinary action against a licensee without discussing whether or not the
licensee had been disciplined in the past. This licensee had previously
received a letter of concern. Additionally, the Board's staff said the Board had
not asked for past disciplinary information.
The Board does not
always clearly explain or
document the basis for
its complaint decision.
Office of the Auditor General
page 15
Complaint Outcome
Number of
Complaints
Evaluated
Number of Board
Decisions
Adequately
Documented
Dismissed 5 3
Dismissed with letter
of concern 6 1
Letter of concern 3 3
Disciplinary action 4 4
Total 18 11
Source: Auditor General staff analysis of complaint documentation and board
meeting minutes for a sample of 5 dismissed complaints and 13
complaints for which the Board issued a letter of concern or took
disciplinary action. Sample was selected from complaints received
between July 1, 2005 and December 31, 2007.
Table 3: Evaluation of Board Documentation
for Complaint Resolution
In August 2008, after audit work was completed, the Board adopted a new
policy to consider disciplinary history. Specifically, the policy states that when
any licensee is called before the Board, the Executive Director will bring the
licensee's file to the meeting. The Executive Director will retain that file until the
Board determines whether or not to take action against a licensee. Only if and
after the Board determines to issue discipline to the licensee will the Executive
Director use the file to provide information to the Board regarding a licensee's
past disciplinary history. This information will be shared for the Board's use in
determining discipline for a licensee.
 Complainant not always notified of complaint outcome—For 15 of the 18
complaints reviewed by auditors that were opened on behalf of a member of
the public, the Board inconsistently communicated the outcome of its
complaint investigation and adjudication to the complainant. Specifically, for
the 5 dismissed complaints reviewed by auditors, documentation for 4 of
these complaints clearly indicated that the Board informed the complainant of
the outcome. However, for the remaining 11 complaints, which include the 1
remaining complaint that was dismissed, 1 complaint where the Board took
disciplinary action, and 9 complaints where the Board issued a
nondisciplinary letter of concern, there is no documentation in the complaint
file indicating that the Board communicated the results of the investigation
and/or the Board's decision to the complainants.
The Office of the Auditor General’s 1998 performance audit and sunset review (see
Report No. 98-15) of the Board also identified similar concerns with the Board's
complaint processing documentation. Although the Board took steps to address
these concerns following the 1998 audit, this audit again identified that the Board
did not adequately document the rationale for its disciplinary decisions and that
the Board did not routinely consider licensees' disciplinary history.
Inadequate processes and documentation have negative impact—
Inadequate complaint processes and documentation increase the risk that board
actions may appear to be inconsistent or biased. Specifically, the Board may
appear to be inconsistent or biased when it does not adequately explain or
document reasons for dismissing complaints, issuing a letter of concern, or taking
disciplinary action—especially when violations or concerns appear similar but
involve different decisions. For example, as noted above, in March 2008 the Board
dismissed a complaint after the Board told the doctor he needed to make
improvements. However, auditors reviewed 6 other complaints for which the Board
issued a nondisciplinary letter of concern for inadequate record-keeping. Because
of the lack of documentation for the Board's decision regarding these complaints,
it is unclear why the Board issued letters of concern for these instances of
inadequate record-keeping, but not for the complaint the Board dismissed in
March 2008. According to the Board's president, the one licensee in the most
recent complaint had quite good documentation, whereas the other licensees who
State of Arizona
page 16
were issued letters of concern for inadequate record-keeping had provided
records to the Board that were grossly inadequate. However, none of this is
documented.
In addition, the Board has no policies and procedures for complaint handling. The
Board should establish and implement complaint-handling policies and
procedures that help ensure the Board consistently and appropriately processes
and documents its processing of all complaints.
Recommendations:
1. The Board should identify and implement a process that allows it to separate its
investigative and adjudicative functions. Options it should consider include:
a. Assigning one of its members to conduct complaint investigation activities,
including reviewing all relevant medical documentation; conducting
necessary interviews of the complainant, licensee, and other appropriate
witnesses; and developing an investigative report or summary for
submission to the Board. This board member should then recuse
himself/herself from all other decisions and discussions regarding the
complaints he/she investigates.
b. Determining whether current or retired podiatrists would volunteer services
to the Board to assist in conducting complaint investigations.
2. The Board should take action against licensees who do not respond in a timely
manner to requests for treatment information as prescribed in statute.
3. The Board should develop and implement policies and procedures that will help
ensure that all complaints are appropriately and completely addressed and that
investigative and adjudicative actions are documented, including policies and
procedures for:
a. Ensuring that all complaint allegations are addressed;
b. Clearly explaining and documenting the basis for complaint decisions;
c. Considering a licensee's disciplinary history when determining discipline for
the new complaint; and
d. Ensuring that the complainant is informed of the Board's decision regarding
the complaint.
Office of the Auditor General
page 17
State of Arizona
page 18
Board should improve public information
The Board of Podiatry Examiners (Board) does not provide complete and/or accurate
public information, whether through staff responses to public inquiries or through the
Board's Web site. The Board should take several steps to help ensure that it provides
accurate and complete information to the public, including addressing deficiencies
with the database used for responding to inquiries and for making information
available on the Web site. Additionally, the Board should supplement its existing
public information guidance with written public information policies and procedures
and conform its records retention policy to its public information policy.
Access to public information important
One of a regulatory board's important responsibilities is providing information that
allows the public to make informed decisions about using the services of licensees
whom the board regulates. For example, by informing the public of disciplinary
actions taken against licensees, boards assist consumers in selecting competent
and ethical professionals. According to the Arizona Agency Handbook, published by
the Arizona Attorney General's Office, Arizona's public records statute seeks to
increase public access to government information and to make government
agencies accountable to the public. According to Arizona Revised Statutes (A.R.S.)
§39-121, public records and other matters in the custody of any [public] officer shall
be open to inspection by any person at all times during office hours. Therefore, all
available board records, unless they are expressly made confidential, should be
provided to the public on request.
Providing information to
the public is an
important regulatory
board responsibility.
Office of the Auditor General
page 19
FINDING 2
Board provides incomplete and/or inaccurate complaint
information
The Board has not provided the public with complete and/or accurate information
regarding a licensee's disciplinary history. Auditors who made telephone calls
requesting information found that board staff did not provide complete information
about licensees. Similarly, the Board's Web site does not provide complete and
accurate licensee complaint information.
Board does not provide complete complaint information by phone—
Auditor General staff called the Board to request information on three different
licensees' complaint histories. For two of the three calls, the Board's employee
provided incomplete public information regarding the licensee's complaint or
disciplinary history when compared to information in the licensee's file and the
Board's database, which contains some information not found in licensee files. For
one call, board staff reported that the Board had received 12 complaints regarding
a licensee but did not fully report the outcome of these complaints. Specifically,
board staff failed to report that any disciplinary actions had been taken, although
the Board had actually disciplined the licensee twice. For the second call, although
board staff reported that the Board issued a letter of concern to the licensee in
1992, staff did not report that a second letter of concern was issued to the licensee
in 2003.
Board does not provide complete and accurate complaint
information on its Web site—The Board's Web site, although helpful, does
not contain accurate and complete information. The Board's Web site provides
useful information, such as licensing forms, board meeting minutes and agendas,
complaint processing information, and licensee complaint and disciplinary history.
Its information about licensee complaint and disciplinary histories, however, is
inaccurate. For example, in February 2008, auditors used the Board's Web site to
look up information about the same three licensees who had been the subject of
the auditors' calls. For two of these three licensees, the information provided by the
Web site was incomplete as compared to the licensees' files.
Further, the Web site information about some licensees was inconsistent from
screen to screen. The Web site directory search function takes the user to two
result screens. The first is a general screen that provides information such as the
licensee's name, city, license number and status, and whether the licensee has
been disciplined and/or received letters of concern (see Figure 1, page 21).
If the licensee's name is selected, a second more detailed results screen is
opened, which provides additional information on the licensee's disciplinary history
(see Figure 2, page 22).
Board staff provided
incomplete complaint
information in response
to auditors' phone calls.
State of Arizona
page 20
Auditors determined that for two of the three licensees referenced in auditors'
phone calls, as well as for two other licensees noted during other audit work, the
information shown in the first results screen contradicted the information from the
second results screen. Specifically, for three of the four licensees, the first screen
listed no discipline although the second screen gave information about disciplinary
action the Board had taken. For the fourth licensee, the first results screen showed
that the licensee had been disciplined, but the second results screen showed no
discipline. Auditors made the Board aware of these discrepancies and later found
that staff had corrected these inconsistencies between Web site results screens for
three of the four licensees mentioned above.
Board's database incomplete and inaccurate
Problems with the Board's database directly contribute to the incomplete and
inaccurate information that is provided to the public. The database forms the basis
of staff responses to public inquiries and the basis of information available on the
Web site. However, the database has the following problems:
 Complaint information incomplete—The Office of the Auditor General’s 1998
performance audit and sunset review of the Board recommended that the Board
develop a complaint-tracking database and procedures to ensure its accuracy
and completeness (see Report No. 98-15). Although the Board took steps to
implement these recommendations, many complaints have not been entered in
The Board's database
directly contributes to
the incomplete and
inaccurate information
provided to the public.
Office of the Auditor General
page 21
Figure 1: Directory Search Results, Web Site Screen #1
Source: Screen copied from the Board's Web site located at www.podiatry.state.az.us as of May 21, 2008, and edited by Auditor General staff to
remove the licensee's personal identifying information.
the database. For example, as of December 10, 2007, the database contained
only 17 of the 45 complaints opened by the Board in 2007 and only 9 of the 123
complaints received between calendar years 2003 and 2006. As of May 13,
2008, auditors found that all of the calendar year 2007 complaints had been
entered into the database, but only 37 of the 123 complaints had been entered
for calendar years 2003 through 2006. Additionally, as of December 2007, only
1 of 23 open complaints had been entered in the database. As a result, staff
cannot use the database to provide open complaint information, and instead
provide information from either a complaint log or the open complaint files.
In addition, information related to many of the complaints that have been
entered into the database is incomplete. Auditors tested 113 complaints in the
database for the completeness of 5 fields that contain complaint information,
such as complaint number, description, status, and disposition, and found that
49 of the complaints were not missing any of this information. However, 64 of the
complaints were missing at least 1 piece of information in these 5 fields.
State of Arizona
page 22
of
Figure 2: State of Arizona Podiatrist Information, Web Site Screen #2
Doctor First Name, Last
Phoenix, AZ 85XXX
Source: Screen copied from the Board's Web site located at www.podiatry.state.az.us as of May 21, 2008, and edited by Auditor General staff to
remove the licensee's personal identifying information.
95-XX
03-XX
 Incorrect field that directly results in Web site inconsistencies—As discussed
above, auditors found that the Board's Web site provides inconsistent complaint
information when comparing the information on two screens. Similar to the Web
site, the database also has a yes/no field that indicates whether the licensee has
either been disciplined by the Board or has been issued a letter of concern. The
information in this database field is manually entered and directly populates the
corresponding field on the first results screen on the Web site. However, auditors
have found this database field to be inaccurate when compared to other
information in the database and hard-copy files. Board staff are aware that this
database field is unreliable and are attempting to correct these inconsistencies
as they are found in the database.
 Limited reporting capabilities—Although the database generates some reports,
such as licensing timeliness reports and a complaint disposition report, as of
May 2008, a report showing an individual licensee's complaint and disciplinary
history has not been created. To provide this information, staff instead manually
search the database for each complaint, record by record, and then separately
total the number of open complaints, letters of concern, disciplinary actions
taken by the Board, and any dismissed complaints. Not only does this take time;
it presents the possibility that information might be missed and not accurately
disclosed.
According to board staff, limited staff and budget resources are the main reasons for
the missing and inaccurate information in the database. However, board staff
reported that as inconsistencies are found, they are being corrected. To help ensure
that the public receives accurate and complete complaint information, the Board
should continue with its efforts to improve the quality of complaint information in its
database, such as entering missing information and correcting inconsistencies, such
as the manually entered yes/no field, which should also correct corresponding
inconsistencies on the Web site. The Board should also develop and implement data
entry and verification policies and procedures for its staff, so that problems such as
inaccurate information about discipline histories can be avoided. Finally, the Board
should add a report to its database that details a licensee's complaint and
disciplinary history. According to the Board, it contracts for information technology
assistance to make changes to its database, including developing various reports,
and should have the resources available to request that its contractor create this
report.1
Board staff lacks clear public information guidance
In addition to the problems with the Board's database, the lack of clear public
information policies and procedures has affected staff's ability to provide complete
and accurate information to the public. Although the Board stated that it developed
The Board should
continue its efforts to
improve the quality of
complaint information in
its database.
1 The Board contracts with the Department of Administration for this IT assistance.
Office of the Auditor General
page 23
The Board's records
retention schedule
conflicts with its public
information guidelines.
public information guidance for its staff in 2006, this guidance has not been
documented in written policy and procedures. According to the Board, its staff
should provide information to the public as follows:
 The number of open complaints;
 The number of dismissed complaints from the previous 5 years;
 The number and nature of complaints that resulted in the Board issuing a letter
of concern from the previous 5 years; and
 The number and nature of all complaints resulting in board disciplinary action.
However, absent written policies and procedures, the Board's staff may not be aware
of the Board's guidance, especially if there is turnover. For example, the board staff
member who was hired in September 2007 and answered the auditor's phone calls
reported that she was unaware that any policy or guidance existed for the provision
of public information. As a result, she did not follow this guidance when providing
information to Auditor General staff over the phone. In the auditor phone call
regarding the licensee who received 12 complaints, board staff did not provide
information on the 2 complaints resulting in disciplinary action, despite the fact that
board guidelines require the provision of this information. Additionally, for this same
phone call, board staff provided information on some complaints that were
dismissed and a letter of concern issued more than 5 years before the auditor's call.
Further, the Board's Web site also does not comply with the Board's public
information guidelines. For example, although board guidelines require staff to report
any open complaints and to report dismissed complaints from the past 5 years,
directory search results on the Web site do not include any information about open
or dismissed complaints.
The Board should develop written policies and procedures for its staff that
incorporate its public information guidance and specify exactly what information
should be provided to the public. Additionally, once the Board develops these
policies and procedures, it should ensure that its Web site is consistent with them.
Finally, once the Board has developed written public information policies and
procedures, it should conform its records retention schedule to these policies and
procedures. A.R.S. §41-1346 requires each agency to develop a records retention
schedule, which should detail how long each public record will be maintained.
Although the Board has a records retention schedule, this schedule conflicts with the
Board's public information guidelines. For example, the Board's records retention
schedule requires that dismissed complaints where the Board takes no disciplinary
action should be retained for 3 years, while the Board's public information guidelines
indicate that information regarding dismissed complaints should be provided to the
public from the previous 5 years. Therefore, the Board should revise its records
retention schedule to conform with its public information policies and procedures.
The Board lacks formal,
written public
information policies and
procedures.
State of Arizona
page 24
Recommendations:
1. To help ensure that accurate and complete information is provided to the public,
the Board should improve the quality of complaint information in its database by:
a. Continuing with its efforts to correct inaccurate information in its database
as it is identified, entering missing complaint information, and entering
complaint information in the database as complaints are received;
b. Developing and implementing data entry and verification policies and
procedures;
c. Continuing with its efforts to address the manually entered yes/no field in
the database, which will correct inconsistencies on the Board's Web site;
and
d. Creating a database report that details a licensee's complaint and
disciplinary history.
2. The Board should develop and implement written policies and procedures that
incorporate its public information guidance and specify the type of information
that staff should disclose regarding complaints. The Board should also ensure
that information provided by its Web site complies with its written policies and
procedures.
3. The Board should revise its records retention schedule to conform with its public
information policies and procedures.
Office of the Auditor General
page 25
State of Arizona
page 26
In accordance with Arizona Revised Statutes (A.R.S.) §41-2954, the Legislature
should consider the following 12 factors in determining whether the Board of Podiatry
Examiners (Board) should be continued or terminated.
1. The objective and purpose in establishing the Board.
The Board licenses and regulates doctors of podiatric medicine who specialize
in the diagnosis and treatment of the foot, ankle, and lower leg. The Board
evaluates the professional competency of podiatrists seeking to be licensed in
the State of Arizona. Further, the Board promotes continued competency and
fitness by investigating complaints made against practitioners, holding
hearings, monitoring the activities of its licensees, and enforcing the standards
of practice for the podiatric profession as set forth by law. The Board also
registers licensees who wish to dispense drugs or podiatric devices.
The Board's mission is "To protect the health, safety, and welfare of the citizens of
Arizona by regulating and maintaining standards of practice in the field of
podiatric medicine." To accomplish its mission, the Board reported that it has
established the following goals: 1) To ensure that licenses and renewals are
issued in a timely manner to competent physicians with high standards of
professional and ethical conduct; 2) To investigate complaints and enforce
standards of practice in a timely manner in order to protect the public from
incompetent services; and 3) To ensure agency policies and procedures,
including testing, renewal, initial licensing, and customer satisfaction, are
effective and efficient.
2. The effectiveness with which the Board has met its objective and purpose and
the efficiency with which it has operated.
The Board has effectively met some of its prescribed purposes and objectives,
but should improve in several areas. For example, the Board approves
continuing education programs and ensures that licensees meet the required
amount of continuing education prior to renewing their licenses. In addition:
Office of the Auditor General
page 27
SUNSET FACTORS
 Overall licensing time frame met—The Board processed most of the initial
licensing applications auditors reviewed within the 90-day overall time
frame. According to the Board's Administrative Rule R4-25-104, the Board
must conduct an administrative review of a license application within 30
days of receipt to verify that the application is complete and a substantive
review and disposition of the application within 60 days, for an overall time
frame of 90 days for both reviews. Auditors' review of a sample of 4 of the
20 license applications processed in fiscal year 2007 found that the Board
processed 3 of these applications within the required overall time frame of
90 days; the fourth license application was processed in 92 days.
 Revised oral exam procedures—As a requirement for licensure, A.R.S. §32-
825 requires applicants to take and pass a state oral exam. In June 2008,
the Board implemented a revised biannual oral exam to include questions
on Arizona podiatry statutes. Prior to this time, the Board's oral exam
predominantly focused on the general practice of podiatry, which,
according to the Board, is content that is also covered in the three national
exams that each license applicant must take and pass. According to the
Board, this change in focus for its state oral exam is in line with other states'
practices and acknowledges applicants successfully passing the national
podiatric exams. In addition to revising the oral exam, the Board improved
the examination procedures. Previous examinations were given during
board meetings and violated several open meeting laws (See Sunset
Factors, pages 27 through 33). The Board did not conduct the June 2008
oral exam in a board meeting, thus avoiding any potential open meeting law
violations.
However, this audit found that the Board can improve the effectiveness and
efficiency of its complaint processing. Specifically:
 Improve processing timeliness of all complaints—The Board needs to
investigate and adjudicate the complaints it receives in a timely manner.
Auditors' review of complaints found that for the 106 complaints the Board
received between July 1, 2005 and December 31, 2007, 27 were open for
more than 180 days, including 12 that were still open as of June 1, 2008.
The 12 complaints included 3 complaints associated with lawsuits that the
Board was monitoring as they progress through the court system. As of
June 1, 2008, the remaining 9 open complaints had been open from 181 to
935 days, including 5 complaints that were open against one licensee.
Because the full Board both investigates and adjudicates complaints, and
it conducts complaint investigations during its board meetings, cases
proceed in accordance with the Board's meeting schedule—one day a
month, which sometimes leads to processing delays. Separating the
Board's investigative and adjudicative functions should help the Board
process complaints in a more timely manner. Additionally, separating the
investigative and adjudicative functions would reduce the potential
State of Arizona
page 28
appearance of bias. Having the full Board perform investigative steps,
including conducting investigative interviews, creates a potential problem
because the Board cannot ensure that all board members then appear
objective when adjudicating the complaint.
Complaint-processing delays also result from licensees failing to respond
in a timely manner to board requests for documentation needed for the
Board's investigation. According to A.R.S. §32-854.01(17), it is an act of
unprofessional conduct for a licensee to refuse “to divulge to the Board on
demand the means, method, procedure, modality of treatment, or
medicine used in the treatment of a disease, injury, ailment, or infirmity.”
Although authorized to take action when a licensee is unresponsive, the
Board has not regularly done so. Therefore, the Board should take action
against licensees who do not respond in a timely manner to board requests
for information as prescribed in statute (see Finding 1, pages 9 through 17).
In July 2008 the Board began using subpoenas to initially request
documentation from licensees. A.R.S. §32-852.01(H) gives the Board
authority to subpoena witnesses, documents, and other evidence as
needed. Using a subpoena may facilitate receiving documentation in a
timely manner because, according to statute, the superior court may hold
a person who refuses to obey a subpoena in contempt of court.
 Improve complaint-handling policies and procedures—The Board should
establish and implement policies and procedures for various aspects of its
complaint handling. These include the following:
o Investigation of all complaint allegations—Auditors were unable to
determine whether the Board addressed all of the allegations identified
in complaints. Although the Board lists complaint allegations in various
documents, including a letter when it requests licensees to appear
before the Board for an investigative interview or in board meeting
minutes, these documents do not clearly indicate that the Board
addressed all of the indicated complaint allegations. Auditors' review
of a judgmental sample of 18 complaints received by the Board
between July 1, 2005 and December 31, 2007, found documentation
supporting that the Board addressed all of the complaint allegations
for only 8 of these 18 complaints.
o Basis for Board's decision—Auditors' review of this same sample of 18
complaints found that for 7 of these complaints, neither board meeting
minutes nor complaint files clearly document enough information to
explain the Board's decisions to dismiss complaints or issue letters of
concern. Additionally, although the Board generally discusses the
basis for its complaint decision during board meetings, auditors
observed that for 3 of 14 cases processed between December 2007
and May 2008, the Board did not clearly explain its reasoning.
Office of the Auditor General
page 29
o Consideration of disciplinary history—The Board imposed discipline
against licensees for 4 of the 18 complaints reviewed by auditors; 2 of
these licensees had previously received discipline. However,
complaint file documentation and/or meeting minutes do not indicate
whether the Board received and or considered information on these
licensees' disciplinary histories when determining the discipline for the
new complaints. In August 2008, the Board adopted a new policy to
consider a licensee’s disciplinary history once the Board determines to
take disciplinary action against a licensee.
o Complainant notification—For 15 of the 18 complaints reviewed by
auditors that were opened on behalf of a member of the public, the
Board inconsistently communicated the outcome of its complaint
investigation and adjudication to the complainant. Specifically, for 11
complaints, which include 1 complaint that was dismissed, 1
complaint where the Board took some form of disciplinary action, and
9 complaints where the Board issued a nondisciplinary letter of
concern, there is no documentation in the complaint file indicating that
the Board communicated the results of the investigation and/or the
Board's decision to the complainant (see Finding 1, pages 9 through
17).
3. The extent to which the Board has operated within the public interest.
The Board has operated in the public interest in some areas, but can improve in
others. For example, the Board has a Web site that provides information to the
public on licensees and board activities. This includes information regarding
licensing and continuing education requirements, licensed podiatrists,
scheduled public meetings, meeting agendas, and minutes from previous
meetings. The Web site also provides access to application forms and provides
information about the Board's complaint process, including how to file a
complaint with the Board. However, auditors identified other areas in which the
Board could better serve the public interest. Specifically:
 Improve the completeness and accuracy of public information—Auditors'
phone calls to the Board and a review of the Board's Web site found that
the Board does not provide complete and accurate information to the
public. Specifically, auditors called the Board to request information on
three different licensees' complaint histories. For two of three requests,
board staff provided incomplete public information regarding the licensees'
complaint or disciplinary history, when compared to information in the
licensee's file and/or in the Board's database. Additionally, auditors used
the Board's Web site to look up information about these same three
licensees and for two of these licensees the information provided by the
Web site was both incomplete and inaccurate as compared to the
licensees' files. Information in the Board's database, which is used by staff
State of Arizona
page 30
to provide public information and is the source of the Board's Web site
information, directly contributes to the problem of incomplete and
inaccurate information. Board staff are aware of the problems with the
database, have begun to address them, and should continue with these
efforts. The Board should also create a database report that will provide the
complaint and disciplinary history for a licensee.
Additionally, the lack of clear, written public information policies and
procedures has affected staff's ability to provide complete and accurate
information to the public. Although the Board reported developing public
information guidance, this guidance has not been documented in written
policy and procedures. Therefore, the Board should develop written
policies and procedures that incorporate its guidance and provide specific
direction on the information that the Board should provide to the public.
Finally, the Board should ensure that its record retention schedule conforms
to its public information policies and procedures (see Finding 2, pages 19
through 25).
 Improve documentation to support applicant's qualifications—Auditors'
review of a sample of 4 of the 20 licensee applications processed in fiscal
year 2007 found documentation to support that the Board adequately
determined that 3 of the 4 applicants met the necessary qualifications to
receive licenses. For these applicants, the Board's licensing files included
documentation of passing scores on the three national board exams, proof
of graduation from podiatry school, completion of a 1-year
internship/residency program, and a completed application. However, for
the fourth license application, the file did not contain documentation to
support that the applicant satisfied all licensure requirements. Specifically,
the Board did not document the receipt of passing scores for 1 of the 3
required national board exams and did not document a copy of the
applicant's podiatry license issued in another state. Although additional
audit work verified that the licensee possessed an active license from
another state at the time he applied for licensure in Arizona, auditors could
not determine whether the applicant passed one of the required national
exams. Therefore, the Board should ensure that it retains documentation to
show that applicants have met all licensure requirements.
4. The extent to which rules adopted by the Board are consistent with the legislative
mandate.
General counsel for the Auditor General has reviewed an analysis of the Board's
rule-making statutes by the Governor's Regulatory Review Council (GRRC) staff,
performed at auditors' request, and believes that the Board has fully established
rules required by statute.
Office of the Auditor General
page 31
5. The extent to which the Board has encouraged input from the public before
adopting its rules and the extent to which it has informed the public as to its
actions and their expected impact on the public.
The Board last amended its rules in fiscal year 2005. In revising its rules, the
Board took a number of steps to inform and involve the public and stakeholders
in the process. For example, the Board filed a formal notice of rulemaking with
the Secretary of State's Office and provided for a period of public review and
comment. Additionally, the Board reported providing information on rules to the
Arizona Podiatric Medical Association (APMA) for their comments and to allow
APMA members to review the changes.
However, the Board has not fully complied with open meeting laws. Auditors
identified several areas where the Board needs to improve its compliance with
these laws. Specifically:
 Meeting notice requirements—According to A.R.S. §38-431.02(A)(1),
agencies must file a statement with the Office of the Secretary of State
identifying where they will post meeting notices. Until January 2008, the
Board did not have such a statement on file with the Secretary of State.
Additionally, until April 2008, board meeting notices did not comply with
A.R.S. §38-431.02(G), which requires state agencies to include a meeting
agenda with the posted notice or inform the public where one could be
obtained at least 24 hours in advance of the meeting. Further, the Board did
not post the notice for the June 11, 2008, board meeting 24 hours in
advance of the meeting. Therefore, the Board should ensure that it
complies with Open Meeting Laws and posts its meeting notices and
appropriate agenda information 24 hours in advance of the meeting.
 Meeting agendas—Although the Board significantly improved its meeting
agendas to comply with open meeting laws during the audit, additional
improvements are needed. At its April 2008 meeting and with the
assistance of the Attorney General's Office, the Board began improving its
agendas by more clearly and specifically identifying the items that it would
be discussing, considering, and potentially acting upon, as required by
A.R.S. §38-431.02(H). However, problems were again identified with its
June 2008 board meeting agenda. Specifically, the Board listed two
complaints on its agenda without listing the specific matters for discussion
or possible action for these complaints. Absent this information, the public,
and in particular, parties to these complaints, do not have sufficient
information to determine whether or not to attend the meeting.
Auditors also identified circumstances where the Board held discussions or
took actions on items that had not been included on the meeting agenda.
This included acting to open new complaints in the March and April 2008
State of Arizona
page 32
board meetings. Additionally, in the January and March 2008 board
meetings, the Board discussed matters raised during the call to the public
segment, which is prohibited by A.R.S. §38-431.01(H). Therefore, the Board
should continue to work with the Attorney General's Office to ensure the
appropriateness of its meeting agendas and that it restrict board business
and discussion to matters that have been appropriately included,
described, and noticed on its meeting agendas.
 Examinations inappropriately conducted—The Board has inappropriately
handled board meetings in which it conducts its oral exams. The Board
holds its oral exam twice a year and, because of the confidential nature of
the exam materials, conducts the exam in an executive session of a board
meeting. However, for the Board's December 2007 oral exam it did not
properly notice the meeting and executive session, post an agenda, or take
and produce meeting minutes. The Board addressed these issues by
holding a meeting to ratify board actions related to the December 2007
exam. Additionally, consistent with the advice of its Assistant Attorney
General to review previous administration of the exams and then address
any potential open meeting law issues, the Board held a ratification meeting
in July 2008.
 Executive sessions—According to A.R.S. §38-431.03, there are seven
reasons that the Board may hold executive session, including discussion or
consultation for legal advice, or receipt and discussion of information or
testimony that is specifically required to be maintained as confidential by
state or federal law. However, in two executive sessions held during
separate board meetings in December 2007 and January 2008, the Board
inappropriately conducted investigative interviews, citing witness safety
concerns. During its May 2008 meeting, the Board's Assistant Attorney
General advised the Board of the problems associated with conducting an
interview in executive session, indicating that witness fear is not a
permissible reason to conduct an interview in executive session and that
the information gathered would need to remain confidential. Therefore, the
Board should ensure that it complies with A.R.S. §38-431.03 and uses
executive session only for purposes permitted by law.
In addition to these noted violations, a complaint was filed with the Arizona
Attorney General's Office regarding potential violations of open meeting law
committed by the Board at the January and February 2008 board meetings. This
complaint alleged several open meeting law violations, including failure to
properly post meeting notices and agendas, that board meeting agendas are
vague, and that the Board failed to properly notice and convene executive
sessions. The Attorney General's Office concluded its investigation in July 2008
and found that although the Board's January 9, 2008, meeting agenda did not
include an investigative interview as the subject of an executive session, the
Office of the Auditor General
page 33
Board remedied this violation by holding another meeting at which this subject
was properly included on the agenda. The Attorney General's Office noted that
the other allegations of the complaint were unfounded and that the Board has
greatly improved its meeting agendas by providing more specificity and detail.
6. The extent to which the Board has been able to investigate and resolve
complaints that are within its jurisdiction.
The agency has sufficient statutory authority and disciplinary options to
investigate and adjudicate complaints within its jurisdiction. However, as
indicated in Sunset Factor 2 (see pages 28 through 29), the Board has not
investigated all complaints in a timely manner and should take steps to process
complaints in a more timely manner, including separating the complaint
investigation and adjudication functions, both of which the full Board performs.
Additionally, the Board should develop and implement policies and procedures
for various aspects of its complaint handing, including addressing all complaint
allegations, clearly explaining and documenting the basis for its complaint
decisions, considering a licensee's disciplinary history when determining
discipline, and notifying complainants of the complaint investigation results and
decision (see Finding 1, pages 9 through 17).
7. The extent to which the Attorney General or any other applicable agency of state
government has the authority to prosecute actions under the enabling
legislation.
A.R.S. §41-192 authorizes the Attorney General's Office to prosecute actions
and represent the Board. The Board is currently represented by one part-time
Assistant Attorney General.
8. The extent to which the Board has addressed deficiencies in its enabling
statutes, which prevent it from fulfilling its statutory mandate.
According to the Board, it has not had any proposed legislation since 2003 and
is not planning to pursue any changes to its enabling statutes.
9. The extent to which changes are necessary in the laws of the Board to
adequately comply with the factors in the sunset law.
This audit did not identify any needed changes to board statutes.
State of Arizona
page 34
10. The extent to which the termination of the Board would significantly harm the
public’s health, safety, or welfare.
Terminating the Board and not otherwise regulating the podiatry profession
would harm the public health, safety, and welfare. The Board is responsible for
ensuring that only qualified applicants are licensed as podiatrists, and
investigating and adjudicating complaints against licensees. Without state laws
establishing educational and competency standards, the public could be
subject to unqualified or incompetent podiatrists. According to information
provided by the American Podiatric Medical Association, all 50 states regulate
podiatrists, but use different regulatory structures for doing so. Thirty-six states
use a podiatry board, 10 use a medical board, and 4 use another form of
regulation; for example, Illinois' Department of Financial and Professional
Regulation and Kansas' State Board of Healing Arts.
In January 2008, the Governor proposed consolidating a number of health
regulatory boards. In May 2008, the Governor's Office reported that the
proposed plan would entail consolidating the administrative services of ten
health-related regulatory boards, including the Board of Podiatry Examiners,
while still maintaining separate boards to hear complaints. According to the
Governor's Office, the model would provide increased accountability to the
public, set a uniform process for licensing in Arizona, and increase the number
of investigators available to the board, resulting in more protection to the public
and leaving more time for the board members to focus on the regulation of the
profession. The Governor's Office invited feedback from the affected regulatory
boards and in June 2008, the Board sent a response to the Governor's Office
declining the invitation to participate in the consolidation efforts. According to the
Board, it chose not to participate in the consolidation because it believes it
would make it more difficult for the public to easily access information about
podiatrists and associated complaints because there would not be a person the
public could speak with who is specialized in podiatry and the complaints filed
with the Board. However, the Governor's Office reported that it plans to continue
to pursue the option because of its benefits for both Arizona licensees and the
public.
11. The extent to which the level of regulation exercised by the Board is appropriate
and whether less or more stringent levels of regulation would be appropriate.
The audit found that the current level of regulation exercised by the Board is
generally appropriate.
Office of the Auditor General
page 35
12. The extent to which the Board has used private contractors in the performance
of its duties and how effective use of private contractors could be accomplished.
The Board uses contractors to perform certain services. For example, the Board
contracts with the Department of Administration for the development and
support of its database and Web site, accounting services, clerical support, and
several other functions. The Board also contracts for administrative rules
development. Additionally, the Board has contracted with private investigators in
the past but reported that it typically does not use private investigators to assist
with complaint investigations because it generally needs investigators with
specialized medical expertise to effectively investigate the types of complaints
against licensed podiatrists and because of the Board's financial situation.
Instead, the Board relies on the expertise of its three professional members to
investigate complaints.
The audit did not identify any additional opportunities to contract for services.
State of Arizona
page 36
Office of the Auditor General
AGENCY RESPONSE
State Of Arizona Board of Podiatry Examiners
1400 W. Washington, Ste. 230
Ph oenix, A Z 85007 www.po diatry.s tate.az.u s
Janet Napolitano de eE.mdoayill:e@ podiatry.az .gov
Governor (6 02) 542- 3095 Fa x: 542-3 093 D ee Doyle
Executive Director
September 19, 2008
Ms. Debbie Davenport, CPA
Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
RE: B oard es Rpon se
Dear Ms. Davenport:
Enclosed please find the State of Arizona Board of Podiatry Examiners response to the Performance Audit recently
conducted by your Staff. We appreciate the opportunity to respond to the Audit Report and Sunset Findings. We also
recognize the diligent effort put forth by your staff in their efforts to understand the Podiatry medical profession and the
Board’s regulation of the profession. The Board is grateful for your work. The Board has addressed the findings as required
by law.
Even though the report is lengthy, it indicates only two findings, which state the following:
1) The Board needs to improve complaint-handling process.
2) The Board should improve public information.
The Board agrees with the findings #1 and #2 and has already instituted numerous steps to implement the recommendations.
The Board feels that the Legislature should consider the best method of regulation of Podiatric Medicine in the State of
Arizona, and make a truly informed choice. We believe that a separate Board of Podiatric Medical Examiners is essential
both to protect the public AND to provide continued availability of these forms of treatment for the public.
Board members do not agree with all of the remarks stated in the Report and recognize that perceptions regarding the
regulated profession are oftentimes misleading. Hopefully, our Agency Response will allow persons reading the Report an
opportunity to come to a reasonable conclusion regarding the Board and the difficulties faced by the agency and its staff.
Thank you again for the efforts of your staff to improve the performance of the Board.
Sincerely,
State of Arizona Board of Podiatry Examiners
Dedrie Polakof, DPM Barry Kaplan, DPM Joseph Leonetti, DPM
Jeanne Reagan, Public Member Paula Hollins, Public Member
Enclosed: Agency Response to Performance Audit Report and Sunset Review Findings.
FINDING I
Recommendations:
1. The Board should identify and implement a process that allows it to separate its investigative and adjudicative
functions. Options it should consider include.
a. Assigning one of its members to conduct complaint investigation activities, including reviewing all
relevant medical documentation; conducting necessary interviews of the complainant, licensee, and
other appropriate witnesses; and developing an investigative report or summary for submission to the
Board. This board member should then recuse himself/herself from all other decisions and discussions
regarding the complaints he/she investigates.
b. Determining whether current or retired podiatrists would volunteer services to the Board to assist in
conducting complaint investigations.
2. The Board should take action against licensees who do not respond to requests for treatment information.
3. The Board should develop and implement policies and procedures that will help ensure that all complaints are
appropriately and completely addresses and that investigative and adjudicative actions are documented,
including policies and procedures for:
a. Ensuring that all complaint allegations are addressed;
b. Clearly explaining and documenting the basis for complaint decisions;
c. Considering a licensee’s disciplinary history when determining discipline for the new complaint; and
d. Ensuring that the complainant is informed of the Board’s decision regarding the complaint.
Response: The finding is agreed to and the recommendations will be implemented.
Status: The Board agrees that a process needs to be implemented to adjudicate complaints. However, there is a
concern that the recommendation for an improved process may result in the Board being less timely in resolving complaints.
The Board could contract with an investigator who is licensed, bonded and an insured podiatrist. The investigator would be
used when difficult complaint cases arise and when the need to obtain testimony from witnesses and obtain medical
information from various sources for the Board to make a more informed decision.
The Board has used licensed podiatrists as expert witnesses in cases to review the medical record and testify.
Due to severe budget constraints, the Board has not used the contract investigator as often as they would like, however the
possible use of a retired podiatrist to volunteer would have to be checked into by the Board.
The Board has taken action against licensees who do not respond in a timely manner in requests for medical documentation.
The Board may also issue disciplinary action against the doctor’s license in the form of a Decree of Censure and/or civil
penalty if records are not provided within the time frame. One license renewal was denied due to not complying with a Board
Order and subpoenas.
The Board will develop and implement policies and procedures that will help ensure that all complaints are appropriately and
completely addressed, including policies and procedures for ensuring that all complaint allegations are addressed; clearly
explaining and documenting the basis for complaint decisions; considering a licensee’s disciplinary history when determining
discipline for the new complaint; and ensuring that the complainant is informed of the Boards’ decision regarding the
complaint.
FINDING II
Recommendations:
1. To help ensure that accurate and complete information is provided to the public, the Board should improve the
quality of complaint information in its database by:
a. Continuing with its efforts to correct inaccurate information in its database as it is identified, entering missing
complaint information, and entering complaint information in the database as complaints are received;
b. Developing and implementing data entry and verification policies and procedures;
c. Continuing with its efforts to address the manually entered yes/no field in the database, which will correct
inconsistencies on the Board’s Web site;
d. Creating a database report that details a licensee’s complaint and disciplinary history.
2. The Board should develop and implement written policies and procedures that incorporate its public information
guidance and specify the type of information that staff should disclose regarding complaints. The Board should
also ensure that information provided by its Web site complies with its written policies and procedures.
3. The Board should revise its records retention schedule to conform to its public information policies and
procedures.
Response: The finding is agreed to and the recommendations will be implemented.
Status: The Board agrees that accurate and complete information is to be provided to the public. The Board needs
to hire a temporary employee to address this need. However, there is a hiring freeze at present and the Governor’s office has
denied the Board the need to hire another Executive Director and a temporary employee to address these needs.
Due to the tremendous increased work load over the past few years on regulation for the Board(s) there is a need to hire a
permanent part-time employee to help complete the recommendations by the auditors and everyday work load and to cover
the office at all times. To correct inaccurate information in its database as identified, entering missing complaint information,
and entering complaint information in the database as complaints are received; develop and implement data entry and
verification policies and procedures; create a database report that details a licensee’s complaint and disciplinary history.
The Board will contact the contract IT person to implement the recommended reports listed above.
The manually entered yes/no field in the database have been implemented to automatically update this field using the
information input into the complaint section of the database. Once the complaint section has been updated completely this
field will be correct.
The Board will revise its record retention schedule to conform to its public information policies and procedures.
SUNSET FACTORS
Recommendation:
1. Improve documentation to support applicant’s qualifications.
Response: The finding is agreed to and the recommendation will be implemented.
2. Meeting notice requirements.
Response: The finding is agreed to and the recommendation will be implemented.
3. Meeting agendas.
Response: The finding is agreed to and the recommendation will be implemented.
4. Examinations inappropriately conducted.
Response: The finding is agreed to and the recommendation will be implemented.
5. Executive sessions.
Response: The finding is agreed to and the recommendation will be implemented.
Status: Several of the recommendations from the auditors on the Sunset Factors have been improved already to
date, the Board will continue to improve the findings from the auditors and act upon them.
Performance Audit Division reports issued within the last 24 months
Future Performance Audit Division reports
Arizona Department of Juvenile Corrections—Rehabilitation and Community Reentry
Arizona Sports and Tourism Authority
07-11 Arizona Supreme Court,
Administrative Office of the
Courts—Juvenile Detention
Centers
07-12 Department of Environmental
Quality—Vehicle Emissions
Inspection Programs
07-13 Arizona Supreme Court,
Administrative Office of the
Courts—Juvenile Treatment
Programs
08-01 Electric Competition
08-02 Arizona’s Universities—
Technology Transfer Programs
08-03 Arizona’s Universities—Capital
Project Financing
08-04 Arizona’s Universities—
Information Technology Security
08-05 Arizona Biomedical Research
Commission
06-09 Department of Health
Services—Behavioral Health
Services for Adults with Serious
Mental Illness in Maricopa
County
07-01 Arizona Board of Fingerprinting
07-02 Arizona Department of Racing
and Arizona Racing Commission
07-03 Arizona Department of
Transportation—Highway
Maintenance
07-04 Arizona Department of
Transportation—Sunset Factors
07-05 Arizona Structural Pest Control
Commission
07-06 Arizona School Facilities Board
07-07 Board of Homeopathic Medical
Examiners
07-08 Arizona State Land Department
07-09 Commission for Postsecondary
Education
07-10 Department of Economic
Security—Division of Child
Support Enforcement

Copyright to this resource is held by the creating agency and is provided here for educational purposes only. It may not be downloaded, reproduced or distributed in any format without written permission of the creating agency. Any attempt to circumvent the access controls placed on this file is a violation of United States and international copyright laws, and is subject to criminal prosecution.

Debra K. Davenport
Auditor General
Performance Audit and Sunset Review
Board of
Podiatry Examiners
Performance Audit Division
September • 2008
REPORT NO. 08-06
A REPORT
TO THE
ARIZONA LEGISLATURE
The is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to
improve the operations of state and local government entities. To this end, she provides financial audits and accounting services
to the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of
school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Audit Staff
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.azauditor.gov
Representative John Nelson, Chair Senator Robert Blendu, Vice Chair
Representative Tom Boone Senator Carolyn Allen
Representative Jack Brown Senator Pamela Gorman
Representative Peter Rios Senator Richard Miranda
Representative Steve Yarbrough Senator Rebecca Rios
Representative Jim Weiers (ex-officio) Senator Tim Bee (ex-officio)
Melanie M. Chesney, Director
Dale Chapman, Manager and Contact Person
Emily Chipman
Robin Hakes
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
September 23, 2008
Members of the Arizona Legislature
The Honorable Janet Napolitano, Governor
Dr. Dedrie Polakof, President
Board of Podiatry Examiners
Dee Doyle, Executive Director
Board of Podiatry Examiners
Transmitted herewith is a report of the Auditor General, A Performance Audit and Sunset
Review of the Board of Podiatry Examiners (Board). This report is in response to an
October 5, 2006, resolution of the Joint Legislative Audit Committee. The performance
audit was conducted as part of the sunset review process prescribed in Arizona Revised
Statutes §41-2951 et seq. I am also transmitting with this report a copy of the Report
Highlights for this audit to provide a quick summary for your convenience.
As outlined in its response, the Board agrees with all of the findings and plans to
implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on September 24, 2008.
Sincerely,
Debbie Davenport
Auditor General
Attachment
The Office of the Auditor General has conducted a performance audit and sunset
review of the Board of Podiatry Examiners (Board) pursuant to an October 5, 2006,
resolution of the Joint Legislative Audit Committee. This audit was conducted as part
of the sunset review process prescribed in Arizona Revised Statutes (A.R.S.) §41-
2951 et seq.
The Board's mission is to protect the health, safety, and welfare of the citizens of
Arizona by maintaining and regulating standards of practice in the field of podiatric
medicine. The Board licenses and regulates podiatrists, who specialize in the
diagnosis and treatment of the foot and its related structures. The Board's various
responsibilities include issuing and renewing licenses to qualified persons,
conducting investigations and hearings concerning unprofessional conduct or other
statutory violations, disciplining licensees who commit violations, and providing
consumer information to the public.
Board needs to improve complaint-handling practices
(see pages 9 through 17)
The Board should take several steps to address problems with its complaint-handling
practices, some of which were identified when the Office of the Auditor
General conducted its 1998 performance audit and sunset review of the Board.
Although the Board took steps to address the 1998 problems, similar problems were
found during this audit. Specifically, the Board should:
 Separate complaint investigation from adjudication—The Board typically
performs the necessary steps to investigate a complaint, but the full Board acts
as both investigator and adjudicator. This practice conflicts with the Attorney
General's guidance in the Arizona Agency Handbook, which states that to
minimize problems, decision-makers, such as board members, involved in
adjudicating a complaint should consider not participating in investigating that
complaint. Combining the investigation and adjudication of complaints can
create the appearance of bias because board members may not appear
objective when adjudicating the complaint. Therefore, the Board should identify
and implement a process that allows it to separate the investigative and
adjudicative functions. One option the Board should consider involves assigning
Office of the Auditor General
SUMMARY
page i
one of its members to conduct complaint investigation activities and then having
this board member recuse himself/herself from all other decisions and
discussions regarding the complaints he/she investigates.
 Improve complaint-handling timeliness—The Auditor General's Office has found
that Arizona health regulatory boards should typically resolve complaints within
180 days. However, it took the Board longer than 180 days to process 15 of the
106 complaints it received between July 1, 2005 and December 31, 2007.
Further, 12 of the 106 complaints remained open as of June 1, 2008, and were
open longer than 180 days, including 5 complaints for one licensee. Two factors
contribute to the Board's inability to process all of the complaints it receives in a
timely manner. First, the Board investigates complaints during its monthly
meetings. Since the Board generally meets only one day per month, complaint
investigations can take considerable time, particularly if the process requires
multiple meetings. Separating the Board's complaint investigation and
adjudication functions, as discussed above, could help it process complaints in
a more timely manner.
Second, licensees are sometimes nonresponsive to board requests for
information. According to statute, it is an act of unprofessional conduct to
withhold some types of information from the Board. A.R.S. §32-854.01(17)
states that it is an act of unprofessional conduct for a licensee to refuse "to
divulge to the board on demand the means, method, procedure, modality of
treatment, or medicine used in the treatment of a disease, injury, ailment or
infirmity." Auditors found that for 4 of the 27 complaints open longer than 180
days and for which the Board issued letters of concern or pursued disciplinary
action, the licensees did not provide information prescribed by statute and were
not sanctioned by the Board. Therefore, the Board should take action against
licensees who do not respond to requests for treatment information as
prescribed in statute. In July 2008, the Board began using subpoenas to initially
request documentation from licensees, which may facilitate how timely
licensees provide documentation to the Board.
 Improve some complaint-handling processes—Because of inadequate
processes and documentation, auditors could not always determine whether
the Board addressed all allegations indicated in a complaint, the basis for its
complaint decisions, and its consideration of a licensee's prior disciplinary
history when determining discipline for a current complaint. Further, the Board
has inconsistently communicated complaint investigation results and the
decision to the complainant. In August 2008 the Board adopted a policy for
consideration of a licensee’s disciplinary history when taking disciplinary action
against a licensee. The Board should also develop and implement complaint-handling
policies and procedures that help ensure that it completely and
appropriately addresses all complaints and documents its processing of all
complaints.
State of Arizona
page ii
Board should improve public information (see pages 19
through 25)
One of a regulatory board's important responsibilities is providing information that
allows the public to make informed decisions about using the services of licensees
whom the Board regulates. However, when auditors made calls to the Board and
asked for information, board staff did not provide complete information about
licensees. Complete information was similarly unavailable on the Board's Web site.
One problem that contributed to the lack of complete information was the Board's
database, which is incomplete and inaccurate. The Office of the Auditor General’s
1998 audit report recommended that the Board develop a complaint-tracking
database and procedures to ensure its accuracy and completeness. Although the
Board took steps to implement these recommendations, as of May 2008, only 37 of
the 123 complaints received between calendar years 2003 and 2006 had been
entered in the database. Further, auditors' tests of 113 complaint records in the
database identified at least one piece of missing information for 64 of these
complaints. Board staff are aware of these problems, have begun to address them,
and should continue to do so. The Board should also create a database report that
can detail an individual licensee's complaint and disciplinary history. As of May 2008,
such a report has not been created in the database, and instead, board staff
manually search the database for this information. This takes time and potentially
leads to information that might be missed or not accurately disclosed to the public.
A second problem affecting the information provided to the public was the lack of
written public information policies and procedures. Although the Board reported that
it had developed public information guidelines for its staff in 2006, it has not
developed formal, written policies. A board employee, who was hired as of
September 2007 and answered auditor phone calls, was unaware of these
guidelines and did not follow them. For example, contrary to board guidance, board
staff provided information on dismissed complaints and a letter of concern that dated
from more than 5 years before the auditor's call and did not provide information on
all complaints that resulted in disciplinary action. Additionally, information on the
Board's Web site is not consistent with its guidelines. To address these matters, the
Board should develop and implement written public information policies and
procedures.
Sunset factors (see pages 27 through 36)
Auditors analyzed the Board's performance in accordance with the 12 sunset factors
outlined in A.R.S. §41-2954, including its compliance with open meeting laws. In
addition to the matters already discussed above, auditors found problems in the
following areas:
Office of the Auditor General
page iii
 Meeting notice requirements—Until April 2008, board meeting notices did not
comply with A.R.S. §38-431.02(G), which requires state agencies, at least 24
hours in advance of the meeting, to include a meeting agenda with the posted
notice or inform the public where one could be obtained. Further, the Board did
not post the notice for its June 11, 2008, board meeting 24 hours in advance of
the meeting. Therefore, the Board should ensure that it complies with the open
meeting law requirement and post its meeting notices and appropriate agenda
information 24 hours in advance of the meeting.
 Meeting agendas—Although the Board significantly improved its meeting
agendas during the audit, additional improvements are needed. Improvements
already made include more clearly and specifically identifying the items to be
discussed, considered, and potentially acted upon. After these changes were
made, however, auditors still found that the June 11, 2008, board meeting
agenda listed two complaints without indicating the specific matters for
discussion or possible action. Auditors also identified circumstances where the
Board held discussions or took actions on items that had not been included on
the meeting agenda. Therefore, the Board should continue to work with the
Attorney General's Office to ensure the appropriateness of its meeting agendas
and that it restrict board business and discussion to matters that have been
appropriately included, described, and noticed on its meeting agendas.
 Examinations inappropriately conducted—One of the Board's duties involves
administering an oral examination to those seeking to become licensed as
podiatrists in Arizona. The Board inappropriately handled its December 2007
oral exam in a board meeting by failing to properly notice the meeting and
executive session, post an agenda, or take and produce meeting minutes. The
Board addressed these issues by holding a meeting to ratify its actions related
to the December 2007 oral exam. Additionally, consistent with the advice of its
Assistant Attorney General to review previous administrations of the exam to see
if this would constitute a meeting and then address any potential open meeting
law issues, the Board held a ratification meeting in July 2008.
 Executive sessions—According to A.R.S. §38-431.03, there are seven reasons
that the Board may hold executive session, including discussion or consultation
for legal advice, or receipt and discussion of information or testimony that is
specifically required to be maintained as confidential by state or federal law.
However, the Board inappropriately conducted investigative interviews, citing
witness safety concerns, in two executive sessions held during separate board
meetings in December 2007 and January 2008. During its May 2008 meeting,
the Board's Assistant Attorney General advised the Board of the problems
associated with conducting an interview in executive session, indicating that
witness fear is not a permissible reason to conduct an interview in executive
session and that the information gathered would need to remain confidential.
Therefore, the Board should ensure that it complies with A.R.S. §38-431.03 and
uses executive session only for purposes permitted by law.
State of Arizona
page iv
Office of the Auditor General
TABLE OF CONTENTS
continued
page v
Introduction & Background 1
Finding 1: Board needs to improve complaint-handling
practices 9
Complaint investigation and adjudication should be separated 9
Board has not processed some complaints in a timely manner 10
Sufficiency of complaint-handling unclear 14
Recommendations 17
Finding 2: Board should improve public information 19
Access to public information important 19
Board provides incomplete and/or inaccurate complaint information 20
Board’s database incomplete and inaccurate 21
Board staff lacks clear public information guidance 23
Recommendations 25
Sunset Factors 27
Agency Response
TABLE OF CONTENTS
concluded
page vi
State of Arizona
Tables:
1 Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2006 through 2008
(Unaudited) 6
2 Status of Complaints Received
Between July 1, 2005 and December 31, 2007
As of June 1, 2008 11
3 Evaluation of Board Documentation
for Complaint Resolution 15
Figures:
1 Directory Search Results, Web Site Screen #1 21
2 State of Arizona Podiatrist Information, Web Site Screen #2 22
The Office of the Auditor General has conducted a performance audit and sunset
review of the Board of Podiatry Examiners (Board) pursuant to an October 5, 2006,
resolution of the Joint Legislative Audit Committee. This audit was conducted as part
of the sunset review process prescribed in Arizona Revised Statutes (A.R.S.) §41-
2951 et seq.
Field of podiatry
The American Medical Association defines "podiatry" as "the branch of medicine that
deals with the examination, diagnosis, and treatment of diseases and malfunctions
of the foot and its related structures." Under A.R.S. §32-801, podiatrists are allowed
to work on any part of the leg below the knee. However, they are not allowed to
administer general anesthesia or perform amputations. Typical foot problems treated
by podiatrists include foot and ankle injuries, bunions, heel spurs, arch problems,
and a variety of diabetes-related problems. Podiatrists generally obtain bachelor's
degrees before entering a 4-year Doctor of Podiatric Medicine program.
Board history and responsibilities
The Board was originally created as the State Board of Chiropody Examiners and
renamed the Board of Podiatry Examiners in 1964. The Board's mission is "To protect
the health, safety, and welfare of the citizens of Arizona by regulating and maintaining
standards of practice in the field of podiatric medicine." The Board has various
responsibilities that are designed to help accomplish its mission, including:
 Issuing and renewing licenses to qualified persons;
 Conducting investigations and hearings concerning unprofessional conduct or
other statutory violations;
 Disciplining violators; and
 Providing consumer information to the public.
In Arizona, podiatrists
may treat any part of the
leg below the knee.
Office of the Auditor General
INTRODUCTION
& BACKGROUND
page 1
Licensure requirements
As part of its responsibilities, the Board issues licenses to qualified applicants.
Qualifications needed to obtain licensure include passing the National Board of
Podiatric Medical Examiners' national board exams with a 75 percent or better score,
graduating from podiatry school, completing a 1-year internship/residency, and
paying the associated $225 licensing fee. Applicants must also take the State's oral
exam and pass with at least a 75 percent score. The Board administers this exam
twice a year, which focuses on Arizona statutes that pertain to the practice of podiatry
in the State. Applicants must pay a $450 fee to take the state oral exam. Statutes also
allow for the Board to issue a provisional license if an applicant meets all of the other
requirements, but has not completed a 1-year internship. However, according to its
staff, the Board has not issued a provisional license in several years.
Podiatrists who are licensed in another state can apply for licensure by comity. To
obtain licensure by comity, the applicant must have practiced podiatry in another
state for not less than 5 years within the 7 years immediately preceding his/her
application for a license in Arizona. In addition, the applicant must also meet all other
requirements for regular licensure, such as graduating from podiatry school and
passing the state oral exam.
Licensees are required to renew their licenses annually. To obtain this renewal,
licensees must complete 25 hours of continuing education in podiatric medicine and
pay a $275 renewal fee. According to board staff, in fiscal year 2007, the Board
issued 14 initial licenses and renewed 346 licenses.1
In addition to issuing licenses, the Board registers licensees to dispense prescription
drugs and devices in Arizona. Licensees must complete an application, submit a
current Drug Enforcement Administration Certification of Registration, and pay the
associated $200 registration fee to become registered. Additionally, this registration
must be renewed annually. In addition to the authority to dispense prescription drugs,
registration authorizes licensees to dispense devices for podiatric care, which,
according to the Board, include ankle or foot orthotics and various braces. In fiscal
year 2007, the Board issued or renewed 228 drug and device dispensing
registrations.2
Regulation of licensees
The Board investigates and adjudicates complaints involving potential statutory
violations and unprofessional conduct by licensed podiatrists, as authorized by
statute. A.R.S. §32-852 states that the Board may, after notice and a hearing,
suspend, revoke, or refuse to issue a license upon proof against the applicant or
The Board issued 14
initial and 346 renewed
licenses in fiscal year
2007.
1 Board staff reported that this information came from the Board's database, which contains unaudited information.
2 Board staff reported that this information came from the Board's database, which contains unaudited information.
State of Arizona
page 2
licensee for six actions that constitute statutory violations for licensees. These actions
are:
 Willfully revealing privileged communication except as required by law;
 Making false or fraudulent statements on a licensing application or
examinations;
 Having a professional association with or lending the use of his/her name to an
unlicensed podiatrist or an illegal practitioner of any of the healing arts;
 Violating A.R.S. §32-854, which states that a license to practice podiatry shall not
be issued to a corporation, partnership, or association, but two or more licensed
podiatrists may occupy and practice in the same office space;
 Being guilty of other conduct that disqualifies the licensee to practice podiatry
with regard to public safety and welfare; and
 Being guilty of unprofessional conduct as defined in A.R.S. §32-854.01.
A.R.S. §32-854.01 further defines unprofessional conduct as 24 different actions,
including advertising in a false, deceptive, or misleading manner; habitual
intemperance in the use of drugs and alcohol; inappropriate use of prescription
drugs; gross malpractice, repeated malpractice, or any malpractice resulting in the
death of a patient; and any conduct or practice which is or might be harmful or
dangerous to the health of the patient.
Allegations of unprofessional conduct may be generated by the public, other
podiatrists, the Arizona Podiatric Medical Association, healthcare institutions, and the
Board. According to board practice, upon receiving a complaint alleging that a
licensee violated statute, board staff notify the named licensee of the complaint and
request that the licensee respond to the allegations and submit pertinent medical
records. The Board then performs additional investigative steps depending on the
circumstances of the case and the type of information that is needed. Investigative
steps may include reviewing submitted medical documentation; interviewing the
licensee, complainant, or witnesses; requesting medical documentation from other
doctors who may have treated a complainant; and seeking evidence through
ordering licensees to submit to drug or psychiatric evaluations. A complaint is
adjudicated when the Board has determined that adequate information has been
obtained to determine whether a violation has or has not been committed.
If after completing its investigation the Board finds that the information is or may be
true, the Board may request an informal interview with the licensee. If the licensee
refuses to attend the informal interview or the results of the interview indicate that
license suspension or revocation may be in order, the Board is required by statute to
issue a complaint and conduct a formal hearing. The Board may conduct the formal
hearing itself or refer the complaint for formal hearing to the Arizona Office of
Office of the Auditor General
page 3
Administrative Hearings to be heard by an administrative law judge. Upon its own
determination or the recommendation of the administrative law judge, the Board
resolves the complaint. If the Board determines the allegations are true, but not of
sufficient seriousness to merit suspension or revocation, the Board can take the
following actions:
 File a letter of concern, which is an advisory letter to notify a podiatrist that
although there is insufficient evidence to support a disciplinary action, the Board
believes the podiatrist should modify or eliminate certain practices and that
continuation of the activities that led to the information being submitted to the
Board may result in action against the podiatrist's license;
 Fix a period and terms of probation;
 Issue a decree of censure;
 Issue a civil penalty of not more than $2,000 per each violation; and/or
 Issue a nondisciplinary order for continuing medical education.
However, if after a formal hearing the Board finds the licensee to be guilty of violating
A.R.S. §32-852, the Board may take the following actions:
 Issue a decree of censure;
 Fix a period and terms of probation; or
 Suspend or revoke a license.
In fiscal year 2007, the Board opened 38 complaints. As of May 2008, board staff
reported that of these 38 complaints, 3 remain open, 30 were dismissed, 4 resulted
in the Board’s issuing a letter of concern, and 1 resulted in the Board’s taking
disciplinary action by issuing a decree of censure.1
Organization and staffing
The Board is made up of three licensed podiatrists and two public members, each
appointed by the Governor to 5-year terms. The Board employs one employee—a
full-time Executive Director who is responsible for most of the Board's administrative
functions, including processing licensing applications, assisting the Board with
complaint handling, and responding to public information requests. In addition, the
Board contracts with the Department of Administration for the use of certain support
services and staff, such as accounting services, financial reporting, and
recordkeeping.
1 Board staff reported that this information came from the Board's database, which contains unaudited information.
State of Arizona
page 4
Budget
The Board derives its revenues from examination and license fees, and registration
fees for licensees to dispense drugs and medical devices. The Board deposits 90
percent of its revenues into the Podiatry Fund and the remaining 10 percent of
revenues into the State General Fund. Table 1 (see page 6) illustrates the Board's
actual revenues and expenditures for fiscal years 2006 through 2008. Due to
increased revenues and decreased expenditures, the Board's financial situation
improved in fiscal year 2008. Specifically, the Board's revenues increased by
approximately 3.4 percent from fiscal years 2006 to 2007, but increased by more
than $31,000, or 25.7 percent, from fiscal years 2007 to 2008. Revenue amounts vary
each fiscal year depending upon when the Board receives and processes the license
and registration fees it collects from April through August of each year. Additionally,
during this time, expenditures had slightly decreased. Specifically, the Board's
expenditures decreased by nearly $11,600, or 9.7 percent, from fiscal years 2007 to
2008. Most of this can be attributed to the savings that resulted from the Board's
executive director position, which was vacant during part of fiscal year 2008, and to
hiring a new executive director who was paid a lower salary than the previous
executive director. However, an $11,400 increase in professional and outside
services costs for temporary clerical help in fiscal year 2008 partially offset these
savings. As a result, the Board's fund balance increased by more than $19,000 to
nearly $86,800 from fiscal year 2006 to 2008.
Despite this improved financial performance in fiscal year 2008 and in response to a
decreasing fund balance in fiscal year 2007, in April 2008, the Board voted to
increase its oral exam fee from $450 to $750, its initial licensure fee from $225 to
$300, and its license renewal fee from $275 to $300. These proposed fee changes
will require revisions to the Board's administrative rules. According to board staff,
these rule revisions are in process and should be completed by June 2009.
Followup to 1998 performance audit and sunset review
The Office of the Auditor General previously performed a performance audit and
sunset review of the Board in 1998 (see Report No. 98-15). The 1998 audit found that
the Board should improve complaint handling by separating its investigation and
adjudication processes, reviewing licensees' disciplinary history to help determine
appropriate discipline for new complaints, and improving its documentation of the
Board's rationale for its decisions. Although the Board took steps to implement these
recommendations, during the current audit, auditors determined that the Board still
needs to take steps to improve its complaint handling. For example, the Board still
needs to separate its investigation and adjudication processes, as well as better
document various aspects of its complaint-handling process, including documenting
the rationale for its decisions (see Finding 1, pages 9 to 17).
Office of the Auditor General
page 5
Additionally, the 1998 audit found that the Board should provide more complete
information to the public by developing and validating a complaint-tracking database
and adopting procedures to ensure the continuing accuracy and completeness of
information in this database. Although the Board took steps to implement these
recommendations, during the current audit, auditors found that the Board still needs
to provide more complete information to the public and that the information in the
Board's complaint database is incomplete (see Finding 2, pages 19 to 25, for more
information).
State of Arizona
page 6
2006 2007 2008
Revenues:
License and registration fees $108,575 $106,425 $134,7921
Examination fees 7,250 12,689 12,600
Fines, forfeits, and penalties 1,800 2,650 2,700
Other 433 270 3,275
Total revenues 118,058 122,034 153,367
Expenditures, operating transfers, and remittances to the State General Fund:2
Personal services and employee-related 72,522 84,813 60,6023
Professional and outside services 26,789 24,988 36,4284
Travel 432 785 534
Other operating 5,387 8,355 9,860
Equipment 267 207
Total expenditures 105,130 119,208 107,631
Operating transfers out 800
Remittances to the State General Fund5 11,806 13,103 15,337
Total expenditures, operating transfers, and
remittances to the State General Fund
116,936 132,311 123,768
Excess (deficiency) of revenues over expenditures,
operating transfers, and remittances 1,122 (10,277) 29,599
Fund balance, beginning of year 66,333 67,455 57,178
Fund balance, end of year $67,455 $57,178 $86,777
Table 1: Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2006 through 2008
(Unaudited)
1 License and registration fees are primarily collected during April through August of each year. Amounts fluctuated
between 2006 and 2008 because in 2008 more receipts were received and processed later in the period.
2 Administrative adjustments are included in the fiscal year paid.
3 Amount decreased significantly in 2008 primarily because the Board did not have an executive director for
approximately 10 weeks and the new executive director was paid a lower salary than the previous executive director.
4 Amount increased significantly in 2008 primarily because temporary services were used when the Board did not
have an executive director.
5 As required by A.R.S. §32-806, the Board remits 10 percent of all revenues to the State General Fund. In addition,
in 2007, the Board remitted a $1,000 civil penalty to the State General Fund.
Source: Auditor General staff analysis of the Arizona Financial Information System (AFIS) Accounting Event Transaction
File for fiscal years 2006 through 2008; and for fund balances, the AFIS Management Information System Status
of General Ledger—Trial Balance screen for fiscal years 2006 through 2008 as of August 6, 2008.
Scope and methodology
This performance audit and sunset review focused on the Board's complaint
investigation and adjudication processes, and its policies and practices for providing
information to the public. The Board's performance was also analyzed in accordance
with the 12 statutory sunset factors. This report includes findings and
recommendations in the following areas:
 Although the Board typically performs the necessary complaint investigative
activities, it should separate the investigation and adjudication of complaints,
process complaints in a more timely manner, and improve various aspects of its
complaint process; and
 The Board should improve the information it provides to the public by ensuring
the completeness and accuracy of information in its database, as well as
developing and implementing consistent policies and practices for providing
information to the public.
In addition, this report contains a response to the 12 statutory sunset factors.
Auditors used various methods to study the issues addressed in this report. These
methods included interviewing board members, the Board's Executive Director, the
Board's Assistant Attorneys General, and a representative of the podiatric
professional association; attending seven of the Board's regular monthly meetings
from December 2007 through June 2008 and two ratification meetings in February
and May 2008; reviewing the Board's statutes, rules, and practices; and reviewing the
Arizona Agency Handbook published by the Attorney General's Office. In addition, the
following specific methods were used:
 To assess the timeliness and adequacy of the Board's processes for
investigating and adjudicating complaints, auditors reviewed and conducted
analyses of the following:
o A judgmental sample of 18 complaints the Board received during fiscal year
2006 through the first half of fiscal year 2008, including a sample of 5
dismissed complaints and all 13 complaints where the Board took
disciplinary action; and
o All 106 complaints the Board received during fiscal year 2006 through the
first half of fiscal year 2008 for timeliness of processing, including files for all
13 complaints processed over 180 days and where the licensee appeared
to have delayed sending documentation to the Board.
In addition, auditors reviewed the Board's complaint-handling documentation
and monthly board meeting minutes from July 2005 through June 2008.
Office of the Auditor General
page 7
 To determine whether the Board provides the public with accurate and complete
information regarding licensee complaint histories and disciplinary actions,
three auditors posing as members of the public made telephone calls to the
Board requesting information on three licensed podiatrists and compared the
information received to the Board's licensee files and database. Further, auditors
reviewed the Board's database for completeness by comparing complaints
entered in the database to all 168 complaint files the Board received from
January 1, 2003 through December 31, 2007. Additionally, auditors tested 113
complaints in the database for the completeness of five fields that contain
complaint information, such as complaint number, description, status, and
disposition. Auditors also observed board staff's processes for using the
database to access the disciplinary history of a licensee. Further, auditors
reviewed the Board's Web site to determine what information is available to the
public and to determine the accuracy of complaint information reported in
disciplinary histories for five licensees. Finally, auditors reviewed the Board’s
public information guidelines and records retention policy.
 To develop information for the Introduction and Background, auditors reviewed
the Auditor General's 1998 performance audit and sunset review of the Board
(see Report No. 98-15); gathered and analyzed information about the Board
from the Arizona Financial Information System (AFIS) Accounting Event
Transaction File for fiscal years 2006 through 2008, and AFIS Management
Information System Status of General Ledger—Trial Balance screen for fiscal
years 2006 through 2008 as of August 6, 2008; and reviewed information from
the American Medical Association’s Web site, the Board's database, and other
board documents.
 To gather information for the sunset factors, auditors reviewed and analyzed a
judgmental sample of 4 of the 20 license applications the Board approved in
fiscal year 2007; an analysis of the Board's administrative rules performed by the
Governor's Regulatory Review Council staff; and the Board's compliance with
open meeting laws, including its statement of disclosure filed with the Arizona
Secretary of State's Office as of January 11, 2008, and board meeting notices,
agendas, and minutes. Auditors also reviewed information from the Master List
of State Government Programs, the American Podiatric Medical Association,
and various board contracts.
This audit was conducted in accordance with government auditing standards.
The Auditor General and staff express appreciation to the board members and the
Executive Director for their cooperation and assistance throughout the audit.
State of Arizona
page 8
Board needs to improve complaint-handling
practices
The Board of Podiatry Examiners (Board) should take several steps to improve its
complaint-handling practices, some of which were identified in the Auditor General's
1998 performance audit and sunset review of the Board (see Report No. 98-15). First,
the Board should separate the investigation of complaints from the adjudication of
complaints. Second, the Board should ensure that it processes all the complaints it
receives in a timely manner. Finally, the Board needs to establish and implement
policies and procedures for various aspects of the complaint-handling process,
including ensuring that it has investigated and adjudicated all complaint allegations,
clearly communicating and documenting the basis for its decisions, and considering
a licensee's disciplinary history when determining discipline.
Complaint investigation and adjudication should be
separated
As was previously recommended in the Office of the Auditor General’s 1998 report,
the Board should separate the investigation of complaints from the adjudication of
complaints. Although the Board took steps to address this recommendation after the
1998 report, auditors' review of board complaint investigation practices and
observations of monthly board meetings between December 2007 and May 2008
found that the Board typically performs the necessary complaint investigative steps
but does not separate the investigation of a complaint from its adjudication. When a
complaint against a licensee is received, the Board's staff requests that the licensee
prepare a response and provide all relevant documentation. During its meetings, the
full Board reviews and discusses complaint-related documentation, determines if
additional documentation is needed and then requests it, interviews complainants if
necessary, and conducts investigative interviews of licensees and other witnesses if
Office of the Auditor General
page 9
FINDING 1
necessary. Following the investigation by the full Board, the Board adjudicates the
complaint and may take various actions such as dismissing the complaint,
scheduling and conducting an informal interview, or referring the matter to formal
hearing, typically with the Office of Administrative Hearings.
The Board's practice conflicts with guidance provided by the Arizona Attorney
General's Office. The Attorney General's Arizona Agency Handbook states that to
minimize problems, decision-makers, such as board members, involved in
adjudicating a complaint should consider not participating in investigating that
complaint. The Board told Auditor General staff that it investigates complaints as a
full board because of the medical expertise required to conduct investigations, which
the three professional board members possess, and because the Board does not
have the resources needed to hire an assistant who is knowledgeable in the field of
podiatric medicine and expert enough to begin investigations on his/her own.
However, combining the investigation and adjudication of complaints can create the
appearance of bias because board members may not appear objective when
adjudicating the complaint.
To help reduce the appearance of bias, the Board should separate its investigative
and adjudicative practices. According to the Arizona Agency Handbook,
investigations can normally be conducted by the Board's staff. However, the Board
has reported that its Executive Director does not have the time or medical knowledge
to complete investigations. Given its limited resources, the Board should identify and
implement some other process that allows separation of the investigative and
adjudicative functions. For example, the Board could assign one of its members to
conduct complaint investigations. This board member could then perform all
necessary complaint investigative activities, such as reviewing all relevant medical
documentation; conducting necessary interviews of the complainant, licensee, and
other appropriate witnesses; and developing an investigative report for submission
to the Board. This board member should then recuse himself/herself from all other
decisions and discussions regarding the complaints he/she investigates.
Alternatively, the Board could determine whether current or retired podiatrists would
volunteer services to the Board to assist in conducting complaint investigations or
identify a combination of methods that would allow it to separate the investigative and
adjudicative functions.
Board has not processed some complaints in a timely
manner
The Board needs to take steps to improve the timeliness of complaint handling.
Although the Board generally processes complaints in a timely manner, it has taken
excessive amounts of time to resolve some complaints. These delays typically
resulted from the Board's practice of investigating complaints during board
meetings, as well as licensees' nonresponsiveness to the Board's requests.
The Board could
assign one member to
investigate complaints;
this member should
not participate in its
adjudication.
State of Arizona
page 10
The full Board both
conducts complaint
investigations and
adjudicates their
outcome.
Some complaints not processed in timely manner—The Auditor
General's Office has found that Arizona health regulatory boards should typically
resolve complaints within 180 days. Additionally, according to the Governor's
executive budget report, the Board has set a goal to complete investigations within
70 days. As illustrated in Table 2, although the Board resolved 79 of the 106
complaints it received between July 1, 2005 and December 31, 2007, within 180
days, it took the Board longer than this time period to resolve 15 complaints.
Further, 12 of the 106 complaints remained open as of June 1, 2008, and were
open longer than 180 days, including 5 complaints for 1 licensee.1 Specifically:
 Licensee with seven open complaints—One licensed podiatrist has seven
open complaints with the Board, including five complaints that have been
open between 200 and over 920 days as of June 1, 2008. According to board
meeting minutes, the initial complaint filed against this licensee in November
2005 alleged unprofessional conduct and excessive billing. Although this
complaint has remained open for
nearly 2½ years, six more complaints
were filed against this licensee in
January 2006, May 2006, September
2006, and November 2007, and two
in May 2008. Allegations against the
doctor include excessive billing,
unsanitary office conditions,
fraudulent billing, practice below the
standard of care and treatment, and
unprofessional conduct with a cease
and desist from any further
communication with the patient or
the patient's family.
The Board said it has been unable to resolve these complaints because it has
not obtained all the information it needs to adequately investigate them. For
example, according to board meeting minutes, the Board attempted to
schedule an initial investigative interview with the licensee at several board
meetings between April and November 2006 in an effort to gather evidence.
However, these interviews have been continually postponed for various
reasons, including at the request of the licensee's lawyers, to allow the
licensee to seek new counsel, and because the Board scheduled other
investigative activities. The Board again scheduled an investigative interview
for its January 2008 board meeting, but was not able to conduct it until the
May 2008 meeting because of the licensee’s requests to postpone the
interview.
Twenty-seven of 106
complaints were open
longer than 180 days.
1 The 12 complaints open past 180 days as of June 1, 2008, include 3 complaints associated with lawsuits that the Board
was monitoring. The remaining 9 complaints were open between 181 and 935 days.
Office of the Auditor General
page 11
Complaint Outcome
Number of
Complaints
Complaints Open
Past 180 Days
Open 12 12
Dismissed 80 8
Letter of concern or
discipline 14 7
Total 106 27
Table 2: Status of Complaints Received
Between July 1, 2005 and December 31, 2007
As of June 1, 2008
Source: Auditor General staff analysis as of June 1, 2008, of all complaints received
by the Board between July 1, 2005 and December 31, 2007.
Investigating complaints
during board meetings
contributes to delays in
processing.
According to board meeting minutes, additional delays resulted from attempts
to schedule a psychiatric evaluation. In November 2006, and in response to
four complaints that alleged excessive office visits, excessive billing, and/or
unsanitary office conditions, the Board ordered the licensee to obtain an
independent psychiatric evaluation. However, the doctor did not receive the
information necessary to comply with the order until January 2007 and as of
June 2008, the licensee had still not complied with this board order, disputing
the Board's choice of psychiatrist, not scheduling the appointment, and
refusing to agree with the psychiatrist's terms of service.
Finally, the licensee has not complied with multiple board orders issued to
obtain evidence, including several subpoenas. For example, in January 2006,
the Board subpoenaed documentation related to the first complaint. In March
2006, the Board added an allegation to the complaint for failure to comply with
the subpoena. At its August 2006 meeting, the Board still had not received a
response to the subpoena and requested a "definitive response" for the
requested records. Despite the licensee's nonresponsiveness, it was not until
its May 2008 meeting that the Board opened a seventh complaint to address
the licensee's noncompliance.
Since some complaint investigations take so long, licensees with potential
problems can continue to practice unchecked. Although complaints must be
properly investigated for the Board to determine whether the alleged statutory
violations are substantiated, lengthy investigations do not adequately serve the
public because licensees who are the subject of valid complaints can continue to
practice for long periods without receiving appropriate disciplinary action and
without addressing the problems identified.
Two factors contribute to delays—Two factors contribute to the Board's
inability to process all the complaints it receives in a timely manner. Specifically:
 Board investigates complaints during board meetings—As discussed above,
the full Board conducts complaint investigations and does so in its board
meetings. The Board generally meets only 1 day per month and as a result,
generally only investigates complaints 1 day per month. Auditors observed
during several board meetings that the Board tabled complaint investigations
pending the request and review of additional medical documentation. This
delays investigations until the Board's next scheduled board meeting, typically
the following month.
Additionally, the Board scheduled investigative interviews for 22 of the
complaints that were open longer than 180 days, but did not schedule 15 of
these interviews for another 2 to 5 months after determining an interview was
needed. As of June 1, 2008, for the 13 interviews which the Board had
Long complaint
investigations can result
in licensees continuing
to practice unchecked.
State of Arizona
page 12
conducted, the average length of time that passed between the date that the
Board determined to hold the interview and when the Board actually
conducted the interview was approximately 103 days. The Board reported that
delays in holding interviews are sometimes necessary because the licensee
may have professional obligations already scheduled for the day of the board
meeting. Separating the Board's complaint investigation and adjudication
functions should help the Board process complaints in a more timely manner,
since investigative activities would be conducted outside of the Board's
meetings.
 Board does not take action when licensees are not responsive—
Investigations are delayed when licensees under investigation do not
cooperate with board requests. Specifically, the Board's initial step in the
investigation process is to request all medical records associated with a
complaint, as well as the licensee's explanation of the case. When licensees
delay responding to the request, this delays the Board's investigation
activities. For 12 of the 27 complaints that took more than 180 days to resolve,
the licensee delayed sending the Board the requested documentation. For
example, in January 2006, the Board received a complaint involving patient
treatment that resulted in the amputation of a toe. At this time, board staff
requested that the licensee provide relevant patient documentation. The
licensee did not fully respond to this request for documentation, but the Board
did not decide to subpoena the documentation until its March 2006 meeting—
almost a month and a half later. The licensee's lawyer provided the requested
documentation to the Board in April 2006 but also told the Board that his client
had not received the subpoena. In addition, the licensee did not provide a
written explanation of the case until early May 2006. Due to these and other
delays, such as a 3-month delay in drafting the consent agreement and order,
the Board took 15 months to investigate and resolve this complaint.
A licensee withholding some types of information requested by the Board
constitutes an act of unprofessional conduct. According to A.R.S. §32-
854.01(17), it is an act of unprofessional conduct for a licensee to refuse "to
divulge to the board on demand the means, method, procedure, modality of
treatment, or medicine used in the treatment of a disease, injury, ailment or
infirmity." However, the Board has not regularly taken action against licensees
who have not responded to subpoenas or written requests for medical
documentation associated with complaints. For example, for 4 of the 27
complaints that were open longer than 180 days and for which the Board
issued letters of concern or pursued disciplinary action, the licensed podiatrist
did not respond in a timely manner to the Board's request for documentation.
However, the Board did not sanction the licensees for the failure to respond in
a timely manner, even though the licensees were required to provide to the
Board the type of information prescribed by statute. The Board said it had not
pursued action against licensees because it previously believed that it could
Office of the Auditor General
page 13
The Board has not
regularly taken action
against licensees who
have not responded to
requests for information.
only take action against a licensee after both requesting the documentation
and then subpoenaing the documentation. Therefore, the Board should take
action against licensees who do not respond in a timely manner to requests
for treatment information as prescribed in statute.
In July 2008, after audit work was completed, the Board began using
subpoenas to initially request documentation from licensees. Further, in
August 2008, the Board formally adopted a policy to use this approach. A.R.S.
§32-852.01(H) gives the Board authority to subpoena witnesses, documents,
and other evidence as needed. Using a subpoena may facilitate receiving
documentation in a timely manner because according to statute, the superior
court may hold a person who refuses to obey a subpoena in contempt of
court.
Sufficiency of complaint-handling unclear
Whether the Board is fully carrying out some parts of its complaint-handling process
is unclear. Specifically, auditors could not always determine whether the Board
considered all allegations indicated in a complaint, the basis for its complaint
decisions, and its consideration of a licensee's disciplinary history when determining
discipline. Further, the Board has inconsistently communicated complaint
investigation results and its decision to the complainant. Inadequate processes and
documentation increase the risk that board actions may appear to be inconsistent or
biased when violations or concerns appear similar but involve different decisions.
Adequacy of some complaint processing uncertain—Because of
inadequate processes and documentation, auditors could not determine whether
the Board adequately processed all complaints reviewed. Specifically:
 Consideration of all complaint allegations unclear—Auditors were unable to
determine whether the Board addressed all of the allegations identified in
complaints. Although the Board lists complaint allegations in various
documents, including a letter when it requests licensees to appear before the
Board for an investigative interview or in board meeting minutes, these
documents do not clearly indicate that the Board addressed all of the
complaint allegations. Specifically, auditors’ review of a judgmental sample of
18 complaints received by the Board between July 1, 2005 and December 31,
2007, found documentation supporting that the Board addressed all of the
complaint allegations for only 8 of the 18 complaints. For example, the Board
issued a letter of concern due to inadequate record-keeping for 6 of the
complaints reviewed. However, complaint documentation and board meeting
minutes do not clearly explain whether the Board addressed the additional
indicated allegations of practice below the standard of care for these
complaints.
The Board does not
clearly address all
complaint allegations.
State of Arizona
page 14
 Basis for decision not always clear—Neither board meeting minutes nor
complaint files consistently document enough information to explain the
Board's decisions to dismiss complaints or issue letters of concern. As shown
in Table 3, auditors' review of a sample of 18 complaints received by the Board
between July 1, 2005 and December 31, 2007, found documentation
explaining the results of the Board's
investigation and/or basis for its decision for
11 of these complaints. These include the 4
complaints where the Board took some
form of disciplinary action, such as placing a
licensee on probation. However, for 2
complaints that the Board dismissed with a
nondisciplinary letter of concern, although
board meeting minutes explain the Board's
rationale for issuing the letter of concern,
complaint documentation does not explain
the Board's decision to dismiss the
complaint. Finally, for the remaining 5
complaints, including 2 dismissed and 3
dismissed with a letter of concern, neither
complaint file documentation nor board
meeting minutes adequately explain the
basis of the Board's complaint decision.
Additionally, although the Board generally discusses the basis for its
complaint decision during the board meeting, auditors observed that for 3 of
the 14 cases processed between December 2007 and May 2008, the Board
did not clearly explain its reasoning.
 Consideration of disciplinary history not clear—Although the Board reported
that it considers a licensee's disciplinary history, including any letters of
concern, when determining discipline for a new complaint, consideration of
this information and its use in helping to determine appropriate discipline is
not documented. Specifically, the Board imposed discipline against licensees
for 4 of the 18 complaints reviewed by auditors. Two of these four licensees
had previously received discipline. However, complaint file documentation
and/or meeting minutes do not indicate whether the Board received or
considered information on these licensees' disciplinary histories when
determining the discipline for the new complaints. The Board indicated that it
sometimes relies on the historical knowledge of board members for this
information or requests the information from staff. Yet, at the December 2007
board meeting, auditors observed the Board considering and then taking
disciplinary action against a licensee without discussing whether or not the
licensee had been disciplined in the past. This licensee had previously
received a letter of concern. Additionally, the Board's staff said the Board had
not asked for past disciplinary information.
The Board does not
always clearly explain or
document the basis for
its complaint decision.
Office of the Auditor General
page 15
Complaint Outcome
Number of
Complaints
Evaluated
Number of Board
Decisions
Adequately
Documented
Dismissed 5 3
Dismissed with letter
of concern 6 1
Letter of concern 3 3
Disciplinary action 4 4
Total 18 11
Source: Auditor General staff analysis of complaint documentation and board
meeting minutes for a sample of 5 dismissed complaints and 13
complaints for which the Board issued a letter of concern or took
disciplinary action. Sample was selected from complaints received
between July 1, 2005 and December 31, 2007.
Table 3: Evaluation of Board Documentation
for Complaint Resolution
In August 2008, after audit work was completed, the Board adopted a new
policy to consider disciplinary history. Specifically, the policy states that when
any licensee is called before the Board, the Executive Director will bring the
licensee's file to the meeting. The Executive Director will retain that file until the
Board determines whether or not to take action against a licensee. Only if and
after the Board determines to issue discipline to the licensee will the Executive
Director use the file to provide information to the Board regarding a licensee's
past disciplinary history. This information will be shared for the Board's use in
determining discipline for a licensee.
 Complainant not always notified of complaint outcome—For 15 of the 18
complaints reviewed by auditors that were opened on behalf of a member of
the public, the Board inconsistently communicated the outcome of its
complaint investigation and adjudication to the complainant. Specifically, for
the 5 dismissed complaints reviewed by auditors, documentation for 4 of
these complaints clearly indicated that the Board informed the complainant of
the outcome. However, for the remaining 11 complaints, which include the 1
remaining complaint that was dismissed, 1 complaint where the Board took
disciplinary action, and 9 complaints where the Board issued a
nondisciplinary letter of concern, there is no documentation in the complaint
file indicating that the Board communicated the results of the investigation
and/or the Board's decision to the complainants.
The Office of the Auditor General’s 1998 performance audit and sunset review (see
Report No. 98-15) of the Board also identified similar concerns with the Board's
complaint processing documentation. Although the Board took steps to address
these concerns following the 1998 audit, this audit again identified that the Board
did not adequately document the rationale for its disciplinary decisions and that
the Board did not routinely consider licensees' disciplinary history.
Inadequate processes and documentation have negative impact—
Inadequate complaint processes and documentation increase the risk that board
actions may appear to be inconsistent or biased. Specifically, the Board may
appear to be inconsistent or biased when it does not adequately explain or
document reasons for dismissing complaints, issuing a letter of concern, or taking
disciplinary action—especially when violations or concerns appear similar but
involve different decisions. For example, as noted above, in March 2008 the Board
dismissed a complaint after the Board told the doctor he needed to make
improvements. However, auditors reviewed 6 other complaints for which the Board
issued a nondisciplinary letter of concern for inadequate record-keeping. Because
of the lack of documentation for the Board's decision regarding these complaints,
it is unclear why the Board issued letters of concern for these instances of
inadequate record-keeping, but not for the complaint the Board dismissed in
March 2008. According to the Board's president, the one licensee in the most
recent complaint had quite good documentation, whereas the other licensees who
State of Arizona
page 16
were issued letters of concern for inadequate record-keeping had provided
records to the Board that were grossly inadequate. However, none of this is
documented.
In addition, the Board has no policies and procedures for complaint handling. The
Board should establish and implement complaint-handling policies and
procedures that help ensure the Board consistently and appropriately processes
and documents its processing of all complaints.
Recommendations:
1. The Board should identify and implement a process that allows it to separate its
investigative and adjudicative functions. Options it should consider include:
a. Assigning one of its members to conduct complaint investigation activities,
including reviewing all relevant medical documentation; conducting
necessary interviews of the complainant, licensee, and other appropriate
witnesses; and developing an investigative report or summary for
submission to the Board. This board member should then recuse
himself/herself from all other decisions and discussions regarding the
complaints he/she investigates.
b. Determining whether current or retired podiatrists would volunteer services
to the Board to assist in conducting complaint investigations.
2. The Board should take action against licensees who do not respond in a timely
manner to requests for treatment information as prescribed in statute.
3. The Board should develop and implement policies and procedures that will help
ensure that all complaints are appropriately and completely addressed and that
investigative and adjudicative actions are documented, including policies and
procedures for:
a. Ensuring that all complaint allegations are addressed;
b. Clearly explaining and documenting the basis for complaint decisions;
c. Considering a licensee's disciplinary history when determining discipline for
the new complaint; and
d. Ensuring that the complainant is informed of the Board's decision regarding
the complaint.
Office of the Auditor General
page 17
State of Arizona
page 18
Board should improve public information
The Board of Podiatry Examiners (Board) does not provide complete and/or accurate
public information, whether through staff responses to public inquiries or through the
Board's Web site. The Board should take several steps to help ensure that it provides
accurate and complete information to the public, including addressing deficiencies
with the database used for responding to inquiries and for making information
available on the Web site. Additionally, the Board should supplement its existing
public information guidance with written public information policies and procedures
and conform its records retention policy to its public information policy.
Access to public information important
One of a regulatory board's important responsibilities is providing information that
allows the public to make informed decisions about using the services of licensees
whom the board regulates. For example, by informing the public of disciplinary
actions taken against licensees, boards assist consumers in selecting competent
and ethical professionals. According to the Arizona Agency Handbook, published by
the Arizona Attorney General's Office, Arizona's public records statute seeks to
increase public access to government information and to make government
agencies accountable to the public. According to Arizona Revised Statutes (A.R.S.)
§39-121, public records and other matters in the custody of any [public] officer shall
be open to inspection by any person at all times during office hours. Therefore, all
available board records, unless they are expressly made confidential, should be
provided to the public on request.
Providing information to
the public is an
important regulatory
board responsibility.
Office of the Auditor General
page 19
FINDING 2
Board provides incomplete and/or inaccurate complaint
information
The Board has not provided the public with complete and/or accurate information
regarding a licensee's disciplinary history. Auditors who made telephone calls
requesting information found that board staff did not provide complete information
about licensees. Similarly, the Board's Web site does not provide complete and
accurate licensee complaint information.
Board does not provide complete complaint information by phone—
Auditor General staff called the Board to request information on three different
licensees' complaint histories. For two of the three calls, the Board's employee
provided incomplete public information regarding the licensee's complaint or
disciplinary history when compared to information in the licensee's file and the
Board's database, which contains some information not found in licensee files. For
one call, board staff reported that the Board had received 12 complaints regarding
a licensee but did not fully report the outcome of these complaints. Specifically,
board staff failed to report that any disciplinary actions had been taken, although
the Board had actually disciplined the licensee twice. For the second call, although
board staff reported that the Board issued a letter of concern to the licensee in
1992, staff did not report that a second letter of concern was issued to the licensee
in 2003.
Board does not provide complete and accurate complaint
information on its Web site—The Board's Web site, although helpful, does
not contain accurate and complete information. The Board's Web site provides
useful information, such as licensing forms, board meeting minutes and agendas,
complaint processing information, and licensee complaint and disciplinary history.
Its information about licensee complaint and disciplinary histories, however, is
inaccurate. For example, in February 2008, auditors used the Board's Web site to
look up information about the same three licensees who had been the subject of
the auditors' calls. For two of these three licensees, the information provided by the
Web site was incomplete as compared to the licensees' files.
Further, the Web site information about some licensees was inconsistent from
screen to screen. The Web site directory search function takes the user to two
result screens. The first is a general screen that provides information such as the
licensee's name, city, license number and status, and whether the licensee has
been disciplined and/or received letters of concern (see Figure 1, page 21).
If the licensee's name is selected, a second more detailed results screen is
opened, which provides additional information on the licensee's disciplinary history
(see Figure 2, page 22).
Board staff provided
incomplete complaint
information in response
to auditors' phone calls.
State of Arizona
page 20
Auditors determined that for two of the three licensees referenced in auditors'
phone calls, as well as for two other licensees noted during other audit work, the
information shown in the first results screen contradicted the information from the
second results screen. Specifically, for three of the four licensees, the first screen
listed no discipline although the second screen gave information about disciplinary
action the Board had taken. For the fourth licensee, the first results screen showed
that the licensee had been disciplined, but the second results screen showed no
discipline. Auditors made the Board aware of these discrepancies and later found
that staff had corrected these inconsistencies between Web site results screens for
three of the four licensees mentioned above.
Board's database incomplete and inaccurate
Problems with the Board's database directly contribute to the incomplete and
inaccurate information that is provided to the public. The database forms the basis
of staff responses to public inquiries and the basis of information available on the
Web site. However, the database has the following problems:
 Complaint information incomplete—The Office of the Auditor General’s 1998
performance audit and sunset review of the Board recommended that the Board
develop a complaint-tracking database and procedures to ensure its accuracy
and completeness (see Report No. 98-15). Although the Board took steps to
implement these recommendations, many complaints have not been entered in
The Board's database
directly contributes to
the incomplete and
inaccurate information
provided to the public.
Office of the Auditor General
page 21
Figure 1: Directory Search Results, Web Site Screen #1
Source: Screen copied from the Board's Web site located at www.podiatry.state.az.us as of May 21, 2008, and edited by Auditor General staff to
remove the licensee's personal identifying information.
the database. For example, as of December 10, 2007, the database contained
only 17 of the 45 complaints opened by the Board in 2007 and only 9 of the 123
complaints received between calendar years 2003 and 2006. As of May 13,
2008, auditors found that all of the calendar year 2007 complaints had been
entered into the database, but only 37 of the 123 complaints had been entered
for calendar years 2003 through 2006. Additionally, as of December 2007, only
1 of 23 open complaints had been entered in the database. As a result, staff
cannot use the database to provide open complaint information, and instead
provide information from either a complaint log or the open complaint files.
In addition, information related to many of the complaints that have been
entered into the database is incomplete. Auditors tested 113 complaints in the
database for the completeness of 5 fields that contain complaint information,
such as complaint number, description, status, and disposition, and found that
49 of the complaints were not missing any of this information. However, 64 of the
complaints were missing at least 1 piece of information in these 5 fields.
State of Arizona
page 22
of
Figure 2: State of Arizona Podiatrist Information, Web Site Screen #2
Doctor First Name, Last
Phoenix, AZ 85XXX
Source: Screen copied from the Board's Web site located at www.podiatry.state.az.us as of May 21, 2008, and edited by Auditor General staff to
remove the licensee's personal identifying information.
95-XX
03-XX
 Incorrect field that directly results in Web site inconsistencies—As discussed
above, auditors found that the Board's Web site provides inconsistent complaint
information when comparing the information on two screens. Similar to the Web
site, the database also has a yes/no field that indicates whether the licensee has
either been disciplined by the Board or has been issued a letter of concern. The
information in this database field is manually entered and directly populates the
corresponding field on the first results screen on the Web site. However, auditors
have found this database field to be inaccurate when compared to other
information in the database and hard-copy files. Board staff are aware that this
database field is unreliable and are attempting to correct these inconsistencies
as they are found in the database.
 Limited reporting capabilities—Although the database generates some reports,
such as licensing timeliness reports and a complaint disposition report, as of
May 2008, a report showing an individual licensee's complaint and disciplinary
history has not been created. To provide this information, staff instead manually
search the database for each complaint, record by record, and then separately
total the number of open complaints, letters of concern, disciplinary actions
taken by the Board, and any dismissed complaints. Not only does this take time;
it presents the possibility that information might be missed and not accurately
disclosed.
According to board staff, limited staff and budget resources are the main reasons for
the missing and inaccurate information in the database. However, board staff
reported that as inconsistencies are found, they are being corrected. To help ensure
that the public receives accurate and complete complaint information, the Board
should continue with its efforts to improve the quality of complaint information in its
database, such as entering missing information and correcting inconsistencies, such
as the manually entered yes/no field, which should also correct corresponding
inconsistencies on the Web site. The Board should also develop and implement data
entry and verification policies and procedures for its staff, so that problems such as
inaccurate information about discipline histories can be avoided. Finally, the Board
should add a report to its database that details a licensee's complaint and
disciplinary history. According to the Board, it contracts for information technology
assistance to make changes to its database, including developing various reports,
and should have the resources available to request that its contractor create this
report.1
Board staff lacks clear public information guidance
In addition to the problems with the Board's database, the lack of clear public
information policies and procedures has affected staff's ability to provide complete
and accurate information to the public. Although the Board stated that it developed
The Board should
continue its efforts to
improve the quality of
complaint information in
its database.
1 The Board contracts with the Department of Administration for this IT assistance.
Office of the Auditor General
page 23
The Board's records
retention schedule
conflicts with its public
information guidelines.
public information guidance for its staff in 2006, this guidance has not been
documented in written policy and procedures. According to the Board, its staff
should provide information to the public as follows:
 The number of open complaints;
 The number of dismissed complaints from the previous 5 years;
 The number and nature of complaints that resulted in the Board issuing a letter
of concern from the previous 5 years; and
 The number and nature of all complaints resulting in board disciplinary action.
However, absent written policies and procedures, the Board's staff may not be aware
of the Board's guidance, especially if there is turnover. For example, the board staff
member who was hired in September 2007 and answered the auditor's phone calls
reported that she was unaware that any policy or guidance existed for the provision
of public information. As a result, she did not follow this guidance when providing
information to Auditor General staff over the phone. In the auditor phone call
regarding the licensee who received 12 complaints, board staff did not provide
information on the 2 complaints resulting in disciplinary action, despite the fact that
board guidelines require the provision of this information. Additionally, for this same
phone call, board staff provided information on some complaints that were
dismissed and a letter of concern issued more than 5 years before the auditor's call.
Further, the Board's Web site also does not comply with the Board's public
information guidelines. For example, although board guidelines require staff to report
any open complaints and to report dismissed complaints from the past 5 years,
directory search results on the Web site do not include any information about open
or dismissed complaints.
The Board should develop written policies and procedures for its staff that
incorporate its public information guidance and specify exactly what information
should be provided to the public. Additionally, once the Board develops these
policies and procedures, it should ensure that its Web site is consistent with them.
Finally, once the Board has developed written public information policies and
procedures, it should conform its records retention schedule to these policies and
procedures. A.R.S. §41-1346 requires each agency to develop a records retention
schedule, which should detail how long each public record will be maintained.
Although the Board has a records retention schedule, this schedule conflicts with the
Board's public information guidelines. For example, the Board's records retention
schedule requires that dismissed complaints where the Board takes no disciplinary
action should be retained for 3 years, while the Board's public information guidelines
indicate that information regarding dismissed complaints should be provided to the
public from the previous 5 years. Therefore, the Board should revise its records
retention schedule to conform with its public information policies and procedures.
The Board lacks formal,
written public
information policies and
procedures.
State of Arizona
page 24
Recommendations:
1. To help ensure that accurate and complete information is provided to the public,
the Board should improve the quality of complaint information in its database by:
a. Continuing with its efforts to correct inaccurate information in its database
as it is identified, entering missing complaint information, and entering
complaint information in the database as complaints are received;
b. Developing and implementing data entry and verification policies and
procedures;
c. Continuing with its efforts to address the manually entered yes/no field in
the database, which will correct inconsistencies on the Board's Web site;
and
d. Creating a database report that details a licensee's complaint and
disciplinary history.
2. The Board should develop and implement written policies and procedures that
incorporate its public information guidance and specify the type of information
that staff should disclose regarding complaints. The Board should also ensure
that information provided by its Web site complies with its written policies and
procedures.
3. The Board should revise its records retention schedule to conform with its public
information policies and procedures.
Office of the Auditor General
page 25
State of Arizona
page 26
In accordance with Arizona Revised Statutes (A.R.S.) §41-2954, the Legislature
should consider the following 12 factors in determining whether the Board of Podiatry
Examiners (Board) should be continued or terminated.
1. The objective and purpose in establishing the Board.
The Board licenses and regulates doctors of podiatric medicine who specialize
in the diagnosis and treatment of the foot, ankle, and lower leg. The Board
evaluates the professional competency of podiatrists seeking to be licensed in
the State of Arizona. Further, the Board promotes continued competency and
fitness by investigating complaints made against practitioners, holding
hearings, monitoring the activities of its licensees, and enforcing the standards
of practice for the podiatric profession as set forth by law. The Board also
registers licensees who wish to dispense drugs or podiatric devices.
The Board's mission is "To protect the health, safety, and welfare of the citizens of
Arizona by regulating and maintaining standards of practice in the field of
podiatric medicine." To accomplish its mission, the Board reported that it has
established the following goals: 1) To ensure that licenses and renewals are
issued in a timely manner to competent physicians with high standards of
professional and ethical conduct; 2) To investigate complaints and enforce
standards of practice in a timely manner in order to protect the public from
incompetent services; and 3) To ensure agency policies and procedures,
including testing, renewal, initial licensing, and customer satisfaction, are
effective and efficient.
2. The effectiveness with which the Board has met its objective and purpose and
the efficiency with which it has operated.
The Board has effectively met some of its prescribed purposes and objectives,
but should improve in several areas. For example, the Board approves
continuing education programs and ensures that licensees meet the required
amount of continuing education prior to renewing their licenses. In addition:
Office of the Auditor General
page 27
SUNSET FACTORS
 Overall licensing time frame met—The Board processed most of the initial
licensing applications auditors reviewed within the 90-day overall time
frame. According to the Board's Administrative Rule R4-25-104, the Board
must conduct an administrative review of a license application within 30
days of receipt to verify that the application is complete and a substantive
review and disposition of the application within 60 days, for an overall time
frame of 90 days for both reviews. Auditors' review of a sample of 4 of the
20 license applications processed in fiscal year 2007 found that the Board
processed 3 of these applications within the required overall time frame of
90 days; the fourth license application was processed in 92 days.
 Revised oral exam procedures—As a requirement for licensure, A.R.S. §32-
825 requires applicants to take and pass a state oral exam. In June 2008,
the Board implemented a revised biannual oral exam to include questions
on Arizona podiatry statutes. Prior to this time, the Board's oral exam
predominantly focused on the general practice of podiatry, which,
according to the Board, is content that is also covered in the three national
exams that each license applicant must take and pass. According to the
Board, this change in focus for its state oral exam is in line with other states'
practices and acknowledges applicants successfully passing the national
podiatric exams. In addition to revising the oral exam, the Board improved
the examination procedures. Previous examinations were given during
board meetings and violated several open meeting laws (See Sunset
Factors, pages 27 through 33). The Board did not conduct the June 2008
oral exam in a board meeting, thus avoiding any potential open meeting law
violations.
However, this audit found that the Board can improve the effectiveness and
efficiency of its complaint processing. Specifically:
 Improve processing timeliness of all complaints—The Board needs to
investigate and adjudicate the complaints it receives in a timely manner.
Auditors' review of complaints found that for the 106 complaints the Board
received between July 1, 2005 and December 31, 2007, 27 were open for
more than 180 days, including 12 that were still open as of June 1, 2008.
The 12 complaints included 3 complaints associated with lawsuits that the
Board was monitoring as they progress through the court system. As of
June 1, 2008, the remaining 9 open complaints had been open from 181 to
935 days, including 5 complaints that were open against one licensee.
Because the full Board both investigates and adjudicates complaints, and
it conducts complaint investigations during its board meetings, cases
proceed in accordance with the Board's meeting schedule—one day a
month, which sometimes leads to processing delays. Separating the
Board's investigative and adjudicative functions should help the Board
process complaints in a more timely manner. Additionally, separating the
investigative and adjudicative functions would reduce the potential
State of Arizona
page 28
appearance of bias. Having the full Board perform investigative steps,
including conducting investigative interviews, creates a potential problem
because the Board cannot ensure that all board members then appear
objective when adjudicating the complaint.
Complaint-processing delays also result from licensees failing to respond
in a timely manner to board requests for documentation needed for the
Board's investigation. According to A.R.S. §32-854.01(17), it is an act of
unprofessional conduct for a licensee to refuse “to divulge to the Board on
demand the means, method, procedure, modality of treatment, or
medicine used in the treatment of a disease, injury, ailment, or infirmity.”
Although authorized to take action when a licensee is unresponsive, the
Board has not regularly done so. Therefore, the Board should take action
against licensees who do not respond in a timely manner to board requests
for information as prescribed in statute (see Finding 1, pages 9 through 17).
In July 2008 the Board began using subpoenas to initially request
documentation from licensees. A.R.S. §32-852.01(H) gives the Board
authority to subpoena witnesses, documents, and other evidence as
needed. Using a subpoena may facilitate receiving documentation in a
timely manner because, according to statute, the superior court may hold
a person who refuses to obey a subpoena in contempt of court.
 Improve complaint-handling policies and procedures—The Board should
establish and implement policies and procedures for various aspects of its
complaint handling. These include the following:
o Investigation of all complaint allegations—Auditors were unable to
determine whether the Board addressed all of the allegations identified
in complaints. Although the Board lists complaint allegations in various
documents, including a letter when it requests licensees to appear
before the Board for an investigative interview or in board meeting
minutes, these documents do not clearly indicate that the Board
addressed all of the indicated complaint allegations. Auditors' review
of a judgmental sample of 18 complaints received by the Board
between July 1, 2005 and December 31, 2007, found documentation
supporting that the Board addressed all of the complaint allegations
for only 8 of these 18 complaints.
o Basis for Board's decision—Auditors' review of this same sample of 18
complaints found that for 7 of these complaints, neither board meeting
minutes nor complaint files clearly document enough information to
explain the Board's decisions to dismiss complaints or issue letters of
concern. Additionally, although the Board generally discusses the
basis for its complaint decision during board meetings, auditors
observed that for 3 of 14 cases processed between December 2007
and May 2008, the Board did not clearly explain its reasoning.
Office of the Auditor General
page 29
o Consideration of disciplinary history—The Board imposed discipline
against licensees for 4 of the 18 complaints reviewed by auditors; 2 of
these licensees had previously received discipline. However,
complaint file documentation and/or meeting minutes do not indicate
whether the Board received and or considered information on these
licensees' disciplinary histories when determining the discipline for the
new complaints. In August 2008, the Board adopted a new policy to
consider a licensee’s disciplinary history once the Board determines to
take disciplinary action against a licensee.
o Complainant notification—For 15 of the 18 complaints reviewed by
auditors that were opened on behalf of a member of the public, the
Board inconsistently communicated the outcome of its complaint
investigation and adjudication to the complainant. Specifically, for 11
complaints, which include 1 complaint that was dismissed, 1
complaint where the Board took some form of disciplinary action, and
9 complaints where the Board issued a nondisciplinary letter of
concern, there is no documentation in the complaint file indicating that
the Board communicated the results of the investigation and/or the
Board's decision to the complainant (see Finding 1, pages 9 through
17).
3. The extent to which the Board has operated within the public interest.
The Board has operated in the public interest in some areas, but can improve in
others. For example, the Board has a Web site that provides information to the
public on licensees and board activities. This includes information regarding
licensing and continuing education requirements, licensed podiatrists,
scheduled public meetings, meeting agendas, and minutes from previous
meetings. The Web site also provides access to application forms and provides
information about the Board's complaint process, including how to file a
complaint with the Board. However, auditors identified other areas in which the
Board could better serve the public interest. Specifically:
 Improve the completeness and accuracy of public information—Auditors'
phone calls to the Board and a review of the Board's Web site found that
the Board does not provide complete and accurate information to the
public. Specifically, auditors called the Board to request information on
three different licensees' complaint histories. For two of three requests,
board staff provided incomplete public information regarding the licensees'
complaint or disciplinary history, when compared to information in the
licensee's file and/or in the Board's database. Additionally, auditors used
the Board's Web site to look up information about these same three
licensees and for two of these licensees the information provided by the
Web site was both incomplete and inaccurate as compared to the
licensees' files. Information in the Board's database, which is used by staff
State of Arizona
page 30
to provide public information and is the source of the Board's Web site
information, directly contributes to the problem of incomplete and
inaccurate information. Board staff are aware of the problems with the
database, have begun to address them, and should continue with these
efforts. The Board should also create a database report that will provide the
complaint and disciplinary history for a licensee.
Additionally, the lack of clear, written public information policies and
procedures has affected staff's ability to provide complete and accurate
information to the public. Although the Board reported developing public
information guidance, this guidance has not been documented in written
policy and procedures. Therefore, the Board should develop written
policies and procedures that incorporate its guidance and provide specific
direction on the information that the Board should provide to the public.
Finally, the Board should ensure that its record retention schedule conforms
to its public information policies and procedures (see Finding 2, pages 19
through 25).
 Improve documentation to support applicant's qualifications—Auditors'
review of a sample of 4 of the 20 licensee applications processed in fiscal
year 2007 found documentation to support that the Board adequately
determined that 3 of the 4 applicants met the necessary qualifications to
receive licenses. For these applicants, the Board's licensing files included
documentation of passing scores on the three national board exams, proof
of graduation from podiatry school, completion of a 1-year
internship/residency program, and a completed application. However, for
the fourth license application, the file did not contain documentation to
support that the applicant satisfied all licensure requirements. Specifically,
the Board did not document the receipt of passing scores for 1 of the 3
required national board exams and did not document a copy of the
applicant's podiatry license issued in another state. Although additional
audit work verified that the licensee possessed an active license from
another state at the time he applied for licensure in Arizona, auditors could
not determine whether the applicant passed one of the required national
exams. Therefore, the Board should ensure that it retains documentation to
show that applicants have met all licensure requirements.
4. The extent to which rules adopted by the Board are consistent with the legislative
mandate.
General counsel for the Auditor General has reviewed an analysis of the Board's
rule-making statutes by the Governor's Regulatory Review Council (GRRC) staff,
performed at auditors' request, and believes that the Board has fully established
rules required by statute.
Office of the Auditor General
page 31
5. The extent to which the Board has encouraged input from the public before
adopting its rules and the extent to which it has informed the public as to its
actions and their expected impact on the public.
The Board last amended its rules in fiscal year 2005. In revising its rules, the
Board took a number of steps to inform and involve the public and stakeholders
in the process. For example, the Board filed a formal notice of rulemaking with
the Secretary of State's Office and provided for a period of public review and
comment. Additionally, the Board reported providing information on rules to the
Arizona Podiatric Medical Association (APMA) for their comments and to allow
APMA members to review the changes.
However, the Board has not fully complied with open meeting laws. Auditors
identified several areas where the Board needs to improve its compliance with
these laws. Specifically:
 Meeting notice requirements—According to A.R.S. §38-431.02(A)(1),
agencies must file a statement with the Office of the Secretary of State
identifying where they will post meeting notices. Until January 2008, the
Board did not have such a statement on file with the Secretary of State.
Additionally, until April 2008, board meeting notices did not comply with
A.R.S. §38-431.02(G), which requires state agencies to include a meeting
agenda with the posted notice or inform the public where one could be
obtained at least 24 hours in advance of the meeting. Further, the Board did
not post the notice for the June 11, 2008, board meeting 24 hours in
advance of the meeting. Therefore, the Board should ensure that it
complies with Open Meeting Laws and posts its meeting notices and
appropriate agenda information 24 hours in advance of the meeting.
 Meeting agendas—Although the Board significantly improved its meeting
agendas to comply with open meeting laws during the audit, additional
improvements are needed. At its April 2008 meeting and with the
assistance of the Attorney General's Office, the Board began improving its
agendas by more clearly and specifically identifying the items that it would
be discussing, considering, and potentially acting upon, as required by
A.R.S. §38-431.02(H). However, problems were again identified with its
June 2008 board meeting agenda. Specifically, the Board listed two
complaints on its agenda without listing the specific matters for discussion
or possible action for these complaints. Absent this information, the public,
and in particular, parties to these complaints, do not have sufficient
information to determine whether or not to attend the meeting.
Auditors also identified circumstances where the Board held discussions or
took actions on items that had not been included on the meeting agenda.
This included acting to open new complaints in the March and April 2008
State of Arizona
page 32
board meetings. Additionally, in the January and March 2008 board
meetings, the Board discussed matters raised during the call to the public
segment, which is prohibited by A.R.S. §38-431.01(H). Therefore, the Board
should continue to work with the Attorney General's Office to ensure the
appropriateness of its meeting agendas and that it restrict board business
and discussion to matters that have been appropriately included,
described, and noticed on its meeting agendas.
 Examinations inappropriately conducted—The Board has inappropriately
handled board meetings in which it conducts its oral exams. The Board
holds its oral exam twice a year and, because of the confidential nature of
the exam materials, conducts the exam in an executive session of a board
meeting. However, for the Board's December 2007 oral exam it did not
properly notice the meeting and executive session, post an agenda, or take
and produce meeting minutes. The Board addressed these issues by
holding a meeting to ratify board actions related to the December 2007
exam. Additionally, consistent with the advice of its Assistant Attorney
General to review previous administration of the exams and then address
any potential open meeting law issues, the Board held a ratification meeting
in July 2008.
 Executive sessions—According to A.R.S. §38-431.03, there are seven
reasons that the Board may hold executive session, including discussion or
consultation for legal advice, or receipt and discussion of information or
testimony that is specifically required to be maintained as confidential by
state or federal law. However, in two executive sessions held during
separate board meetings in December 2007 and January 2008, the Board
inappropriately conducted investigative interviews, citing witness safety
concerns. During its May 2008 meeting, the Board's Assistant Attorney
General advised the Board of the problems associated with conducting an
interview in executive session, indicating that witness fear is not a
permissible reason to conduct an interview in executive session and that
the information gathered would need to remain confidential. Therefore, the
Board should ensure that it complies with A.R.S. §38-431.03 and uses
executive session only for purposes permitted by law.
In addition to these noted violations, a complaint was filed with the Arizona
Attorney General's Office regarding potential violations of open meeting law
committed by the Board at the January and February 2008 board meetings. This
complaint alleged several open meeting law violations, including failure to
properly post meeting notices and agendas, that board meeting agendas are
vague, and that the Board failed to properly notice and convene executive
sessions. The Attorney General's Office concluded its investigation in July 2008
and found that although the Board's January 9, 2008, meeting agenda did not
include an investigative interview as the subject of an executive session, the
Office of the Auditor General
page 33
Board remedied this violation by holding another meeting at which this subject
was properly included on the agenda. The Attorney General's Office noted that
the other allegations of the complaint were unfounded and that the Board has
greatly improved its meeting agendas by providing more specificity and detail.
6. The extent to which the Board has been able to investigate and resolve
complaints that are within its jurisdiction.
The agency has sufficient statutory authority and disciplinary options to
investigate and adjudicate complaints within its jurisdiction. However, as
indicated in Sunset Factor 2 (see pages 28 through 29), the Board has not
investigated all complaints in a timely manner and should take steps to process
complaints in a more timely manner, including separating the complaint
investigation and adjudication functions, both of which the full Board performs.
Additionally, the Board should develop and implement policies and procedures
for various aspects of its complaint handing, including addressing all complaint
allegations, clearly explaining and documenting the basis for its complaint
decisions, considering a licensee's disciplinary history when determining
discipline, and notifying complainants of the complaint investigation results and
decision (see Finding 1, pages 9 through 17).
7. The extent to which the Attorney General or any other applicable agency of state
government has the authority to prosecute actions under the enabling
legislation.
A.R.S. §41-192 authorizes the Attorney General's Office to prosecute actions
and represent the Board. The Board is currently represented by one part-time
Assistant Attorney General.
8. The extent to which the Board has addressed deficiencies in its enabling
statutes, which prevent it from fulfilling its statutory mandate.
According to the Board, it has not had any proposed legislation since 2003 and
is not planning to pursue any changes to its enabling statutes.
9. The extent to which changes are necessary in the laws of the Board to
adequately comply with the factors in the sunset law.
This audit did not identify any needed changes to board statutes.
State of Arizona
page 34
10. The extent to which the termination of the Board would significantly harm the
public’s health, safety, or welfare.
Terminating the Board and not otherwise regulating the podiatry profession
would harm the public health, safety, and welfare. The Board is responsible for
ensuring that only qualified applicants are licensed as podiatrists, and
investigating and adjudicating complaints against licensees. Without state laws
establishing educational and competency standards, the public could be
subject to unqualified or incompetent podiatrists. According to information
provided by the American Podiatric Medical Association, all 50 states regulate
podiatrists, but use different regulatory structures for doing so. Thirty-six states
use a podiatry board, 10 use a medical board, and 4 use another form of
regulation; for example, Illinois' Department of Financial and Professional
Regulation and Kansas' State Board of Healing Arts.
In January 2008, the Governor proposed consolidating a number of health
regulatory boards. In May 2008, the Governor's Office reported that the
proposed plan would entail consolidating the administrative services of ten
health-related regulatory boards, including the Board of Podiatry Examiners,
while still maintaining separate boards to hear complaints. According to the
Governor's Office, the model would provide increased accountability to the
public, set a uniform process for licensing in Arizona, and increase the number
of investigators available to the board, resulting in more protection to the public
and leaving more time for the board members to focus on the regulation of the
profession. The Governor's Office invited feedback from the affected regulatory
boards and in June 2008, the Board sent a response to the Governor's Office
declining the invitation to participate in the consolidation efforts. According to the
Board, it chose not to participate in the consolidation because it believes it
would make it more difficult for the public to easily access information about
podiatrists and associated complaints because there would not be a person the
public could speak with who is specialized in podiatry and the complaints filed
with the Board. However, the Governor's Office reported that it plans to continue
to pursue the option because of its benefits for both Arizona licensees and the
public.
11. The extent to which the level of regulation exercised by the Board is appropriate
and whether less or more stringent levels of regulation would be appropriate.
The audit found that the current level of regulation exercised by the Board is
generally appropriate.
Office of the Auditor General
page 35
12. The extent to which the Board has used private contractors in the performance
of its duties and how effective use of private contractors could be accomplished.
The Board uses contractors to perform certain services. For example, the Board
contracts with the Department of Administration for the development and
support of its database and Web site, accounting services, clerical support, and
several other functions. The Board also contracts for administrative rules
development. Additionally, the Board has contracted with private investigators in
the past but reported that it typically does not use private investigators to assist
with complaint investigations because it generally needs investigators with
specialized medical expertise to effectively investigate the types of complaints
against licensed podiatrists and because of the Board's financial situation.
Instead, the Board relies on the expertise of its three professional members to
investigate complaints.
The audit did not identify any additional opportunities to contract for services.
State of Arizona
page 36
Office of the Auditor General
AGENCY RESPONSE
State Of Arizona Board of Podiatry Examiners
1400 W. Washington, Ste. 230
Ph oenix, A Z 85007 www.po diatry.s tate.az.u s
Janet Napolitano de eE.mdoayill:e@ podiatry.az .gov
Governor (6 02) 542- 3095 Fa x: 542-3 093 D ee Doyle
Executive Director
September 19, 2008
Ms. Debbie Davenport, CPA
Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
RE: B oard es Rpon se
Dear Ms. Davenport:
Enclosed please find the State of Arizona Board of Podiatry Examiners response to the Performance Audit recently
conducted by your Staff. We appreciate the opportunity to respond to the Audit Report and Sunset Findings. We also
recognize the diligent effort put forth by your staff in their efforts to understand the Podiatry medical profession and the
Board’s regulation of the profession. The Board is grateful for your work. The Board has addressed the findings as required
by law.
Even though the report is lengthy, it indicates only two findings, which state the following:
1) The Board needs to improve complaint-handling process.
2) The Board should improve public information.
The Board agrees with the findings #1 and #2 and has already instituted numerous steps to implement the recommendations.
The Board feels that the Legislature should consider the best method of regulation of Podiatric Medicine in the State of
Arizona, and make a truly informed choice. We believe that a separate Board of Podiatric Medical Examiners is essential
both to protect the public AND to provide continued availability of these forms of treatment for the public.
Board members do not agree with all of the remarks stated in the Report and recognize that perceptions regarding the
regulated profession are oftentimes misleading. Hopefully, our Agency Response will allow persons reading the Report an
opportunity to come to a reasonable conclusion regarding the Board and the difficulties faced by the agency and its staff.
Thank you again for the efforts of your staff to improve the performance of the Board.
Sincerely,
State of Arizona Board of Podiatry Examiners
Dedrie Polakof, DPM Barry Kaplan, DPM Joseph Leonetti, DPM
Jeanne Reagan, Public Member Paula Hollins, Public Member
Enclosed: Agency Response to Performance Audit Report and Sunset Review Findings.
FINDING I
Recommendations:
1. The Board should identify and implement a process that allows it to separate its investigative and adjudicative
functions. Options it should consider include.
a. Assigning one of its members to conduct complaint investigation activities, including reviewing all
relevant medical documentation; conducting necessary interviews of the complainant, licensee, and
other appropriate witnesses; and developing an investigative report or summary for submission to the
Board. This board member should then recuse himself/herself from all other decisions and discussions
regarding the complaints he/she investigates.
b. Determining whether current or retired podiatrists would volunteer services to the Board to assist in
conducting complaint investigations.
2. The Board should take action against licensees who do not respond to requests for treatment information.
3. The Board should develop and implement policies and procedures that will help ensure that all complaints are
appropriately and completely addresses and that investigative and adjudicative actions are documented,
including policies and procedures for:
a. Ensuring that all complaint allegations are addressed;
b. Clearly explaining and documenting the basis for complaint decisions;
c. Considering a licensee’s disciplinary history when determining discipline for the new complaint; and
d. Ensuring that the complainant is informed of the Board’s decision regarding the complaint.
Response: The finding is agreed to and the recommendations will be implemented.
Status: The Board agrees that a process needs to be implemented to adjudicate complaints. However, there is a
concern that the recommendation for an improved process may result in the Board being less timely in resolving complaints.
The Board could contract with an investigator who is licensed, bonded and an insured podiatrist. The investigator would be
used when difficult complaint cases arise and when the need to obtain testimony from witnesses and obtain medical
information from various sources for the Board to make a more informed decision.
The Board has used licensed podiatrists as expert witnesses in cases to review the medical record and testify.
Due to severe budget constraints, the Board has not used the contract investigator as often as they would like, however the
possible use of a retired podiatrist to volunteer would have to be checked into by the Board.
The Board has taken action against licensees who do not respond in a timely manner in requests for medical documentation.
The Board may also issue disciplinary action against the doctor’s license in the form of a Decree of Censure and/or civil
penalty if records are not provided within the time frame. One license renewal was denied due to not complying with a Board
Order and subpoenas.
The Board will develop and implement policies and procedures that will help ensure that all complaints are appropriately and
completely addressed, including policies and procedures for ensuring that all complaint allegations are addressed; clearly
explaining and documenting the basis for complaint decisions; considering a licensee’s disciplinary history when determining
discipline for the new complaint; and ensuring that the complainant is informed of the Boards’ decision regarding the
complaint.
FINDING II
Recommendations:
1. To help ensure that accurate and complete information is provided to the public, the Board should improve the
quality of complaint information in its database by:
a. Continuing with its efforts to correct inaccurate information in its database as it is identified, entering missing
complaint information, and entering complaint information in the database as complaints are received;
b. Developing and implementing data entry and verification policies and procedures;
c. Continuing with its efforts to address the manually entered yes/no field in the database, which will correct
inconsistencies on the Board’s Web site;
d. Creating a database report that details a licensee’s complaint and disciplinary history.
2. The Board should develop and implement written policies and procedures that incorporate its public information
guidance and specify the type of information that staff should disclose regarding complaints. The Board should
also ensure that information provided by its Web site complies with its written policies and procedures.
3. The Board should revise its records retention schedule to conform to its public information policies and
procedures.
Response: The finding is agreed to and the recommendations will be implemented.
Status: The Board agrees that accurate and complete information is to be provided to the public. The Board needs
to hire a temporary employee to address this need. However, there is a hiring freeze at present and the Governor’s office has
denied the Board the need to hire another Executive Director and a temporary employee to address these needs.
Due to the tremendous increased work load over the past few years on regulation for the Board(s) there is a need to hire a
permanent part-time employee to help complete the recommendations by the auditors and everyday work load and to cover
the office at all times. To correct inaccurate information in its database as identified, entering missing complaint information,
and entering complaint information in the database as complaints are received; develop and implement data entry and
verification policies and procedures; create a database report that details a licensee’s complaint and disciplinary history.
The Board will contact the contract IT person to implement the recommended reports listed above.
The manually entered yes/no field in the database have been implemented to automatically update this field using the
information input into the complaint section of the database. Once the complaint section has been updated completely this
field will be correct.
The Board will revise its record retention schedule to conform to its public information policies and procedures.
SUNSET FACTORS
Recommendation:
1. Improve documentation to support applicant’s qualifications.
Response: The finding is agreed to and the recommendation will be implemented.
2. Meeting notice requirements.
Response: The finding is agreed to and the recommendation will be implemented.
3. Meeting agendas.
Response: The finding is agreed to and the recommendation will be implemented.
4. Examinations inappropriately conducted.
Response: The finding is agreed to and the recommendation will be implemented.
5. Executive sessions.
Response: The finding is agreed to and the recommendation will be implemented.
Status: Several of the recommendations from the auditors on the Sunset Factors have been improved already to
date, the Board will continue to improve the findings from the auditors and act upon them.
Performance Audit Division reports issued within the last 24 months
Future Performance Audit Division reports
Arizona Department of Juvenile Corrections—Rehabilitation and Community Reentry
Arizona Sports and Tourism Authority
07-11 Arizona Supreme Court,
Administrative Office of the
Courts—Juvenile Detention
Centers
07-12 Department of Environmental
Quality—Vehicle Emissions
Inspection Programs
07-13 Arizona Supreme Court,
Administrative Office of the
Courts—Juvenile Treatment
Programs
08-01 Electric Competition
08-02 Arizona’s Universities—
Technology Transfer Programs
08-03 Arizona’s Universities—Capital
Project Financing
08-04 Arizona’s Universities—
Information Technology Security
08-05 Arizona Biomedical Research
Commission
06-09 Department of Health
Services—Behavioral Health
Services for Adults with Serious
Mental Illness in Maricopa
County
07-01 Arizona Board of Fingerprinting
07-02 Arizona Department of Racing
and Arizona Racing Commission
07-03 Arizona Department of
Transportation—Highway
Maintenance
07-04 Arizona Department of
Transportation—Sunset Factors
07-05 Arizona Structural Pest Control
Commission
07-06 Arizona School Facilities Board
07-07 Board of Homeopathic Medical
Examiners
07-08 Arizona State Land Department
07-09 Commission for Postsecondary
Education
07-10 Department of Economic
Security—Division of Child
Support Enforcement